A 60 year old male with decreased urine output and pedal edema

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 60 year old male with chief complaints of decreased urine output since 2months and pedal edema since 1 month.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 2 months back then he had decreased urine output i.e once a day with hesitancy and not associated with urgency, burning micturition,hematuria,post void pain or dripping ,retention of urine. He developed pedal edema since 1 month which is of pitting type associated with facial puffiness and back pain.He developed fever which is insidious in onset , gradually progressive, intermittent,low grade with evening rise of temperature and night sweats and subsided with medication.It is associated with chills,cough without sputum, shortness of breath even at rest(grade 4) with orthopnoea, paroxysmal nocturnal dyspnoea and no h/o chest pain and palpitations.

PAST HISTORY:

Diabetes mellitus since 8 years,takes insulin injections.Hypertension since 10years and uses nifedipine 10mg.

Right hemiplegia 5years back.

No h/o tuberculosis,coronary artery disease,epilepsy.

No h/o any surgeries

FAMILY HISTORY:

No similar complaints in the family


PERSONAL HISTORY:

Sleep:adequate

Appetite: decreased

Bowel movements: regular

Bladder movements:decreased urine output

Addictions:none 


FAMILY HISTORY: 

No similar complaints in the family

GENERAL EXAMINATION

Patient is conscious, coherent, and comfortable
No pallor, No icterus, No clubbing, No lymphadenopathy, No cyanosis.

Pedal edema is present,pitting type


SYSTEMIC examination:

CVS:
S1 S2 heard
No murmurs

RESPIRATORY SYSTEM:
Inspection-chest is symmetrical 
Respiratory movements are symmetrical 
Trachea is center
Normal vesicular breath sounds heard

ABDOMEN:
Abdomen is not distended
No tenderness and no local rise in temperature 
No palpable mass
LIVER- not palpable
SPLEEN- not palpable
Bowel sounds - heard

CNS:
No focal neurological deficits

INVESTIGATIONS





PROVISIONAL DIAGNOSIS:

Chronic kidney disease on hemodialysis 

TREATMENT:

T.Nicardia 10mg PO/BD

T.Orofer 10mg PO/OD

T.Shelcal 500mg PO/OD

Inj.EPO 4000 IU/SC once weekly

Inj.HAI SC TID as per GRBS

Syrup Cremaffin 15ml PO/HS

T.Ecospirin 75mg PO/HS

T.Torsemide 100mg PO/BD

T.Clonidine 0.1mg PO/OD

T Bisoprolol 25mg PO/OD

Salt restriction <2gm/day

Fluid restriction <1.5 lit/day

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