A 65 year old female patient with CKD

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. 
Chief complaint: 
A 65 years old female with chief complaints of
-pedal edema since - 3months.
-Shortness of breath since - 3 months
- Decreased urine output since 3 months. 
History of present illness:- 
patient was apparently asymptomatic 1yr back then she noticed decreased  urine output and was diagnosed to have  heart failure and renal  failure and started on conservative management. 
Then 3months back she noticed increased Bilateral pedal edema -pitting type, extending till ankles . 
shortness of breath - grade 3 insidious onset and progressive.
No history of burning micturition,  pnd,cough, cold, fever.
History of past illness: - 
K/C/O Hypertension since 30 years, diabetes mellitus since 30 years
Not known case of asthma, tuberculosis, epilepsy.
Treatment history:  
For diabetes Tab Glimi 3mg/PO/BD.
For hypertension tab nicardia , arkamine. 
Personal history :
  Diet - Mixed
 Appetite - Lost 
 Bowel and bladder movements- Irregular ( constipation) 
 Sleep - Adequate
 Micturition - Abnormal
 No addictions.

Family history:- No one of family has similar disease.

General Examination:
Patient is co-operative coherent consciousness and well oriented to place and time . 
No pallor, cyanosis, icterus, lymphadenopathy, clubbing of fingers.

Vitals : -
 Temperature - 98 °F
 Bp - 160/100
Pulse rate - 100/min
Respiratory rate - 16 times / min.

Systemic Examination -   
  
Respiratory system 
Inspection : -
Chest is normal bilaterally symmetrical 
Position of trachea is central 
Movements are bilaterally symmetrical.
No scars , sinuses, or visible pulsations.
Suprasternal and supraclavicular notching is present.
Palpation :
No local rise of temperature
No tenderness
All inspectory findings are confirmed
Apex beat felt in 5th intercostal space 2cm lateral to midclavicular line .
Percussion
Resonent sound is heard
Auscultation 
Normal vesicular sounds are heard.

CVS -
inspection :
Bilaterally symmetrical chest
No visible  engorged veins,scars or sinuses on chest.
Palpation :
S1 S2 are heard
No thrills , no murmurs 
Apex beat present at 5th intercostal space 2cm  lateral to midclavicular line .
Auscultation : 
Cardiac rate - 100 beats per minute 
No cardiac murmurs heard.

Abdomen - 
Obese, inverted umbilicus. 
No visible scars, sinuses, fistulasfistulas, engorged veins.
No organomegaly. 
Soft , non tender , no free fluid. 
CNS -
Conscious, speech is normal, no neck stiffness and kernings sign negative.
No finger and nose in coordination.
provisional diagnosis: - Chronic renal failure 
HFpEF - Right heart failure

Investigations: - 
2D echo 

USG ABDOMEN 
 complete urine examination 
 Random blood sugar 
 serum creatinine 
 Serum electrolytes 
 ECG 
 Complete blood picture 
 
  

 
Management:- Hemodialysis
Tab Nodosis
Tab shelcal
Tab orofer
Cap BioN
Tab Nicardia
Inj Erythropoietin
Salbutamol nebulisations


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