57 year male with Shortness of breath and swelling in legs.

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians signed informed consent.

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve the patients  clinical problem with current best evidence based input.

This Elog also reflects my patient centered online learning portfolio.
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 a diagnosis and treatment plan.


A 57 year old man came to old for follow up for dialysis.

Patient was apparently asymptomatic 5 years back and was diagnosed with diabetes and hypertension.He was on regular medication.
He went to the physician for swelling in the legs feet hands and facial puffiness then diagnosed as renal disease.He underwent 2 sessions of dialysis.
A year ago there was sudden development of weakness of left limbs immediately after waking up in the morning while having milk.He fell down on the ground and speech was inappropriate.No flaccidity of muscles,No sensory deficit.Went to the physician.He was under medication and physiotherapy. They also used some herbal medications.Now tone and power of muscles improved.He can lift his hand above the level of his shoulders.
10 days ago patient developed puffiness of face,abdominal distention and grade 3 sob for which they advised for dialysis.came to narketpally for the same.

Past history 
History of Diabetes, hypertension and cva
No history of Asthma, TB

Personal history 
Mixed diet 
Loss of appetite since 10 days
Bowel and bladder movements are regular 
No allergies 
Stopped non veg 1 year ago
Occasional Alcoholic drinkerstopped 1 year back

Family history 
Not significant 

General examination 
Patient is conscious coherent and coperative well oriented to time place and person 
Mild pallor no icterus  cyanosis clubbing  lymphadenopathy 
Bilateral pitting type of edema upto ankle
Vitals 
Afebrile
 Pulse rate 89bpm
Bp 180/110 mmhg
Systemic examination 
 Cvs examination 
S1 s2 heard no murmurs 

Respiratory system 
Normal vesicular breath sounds heard 

Abdomen 
Shape is obese
No tenderness 
No organomegaly


Central nervous system 
Conscious 
Speech is normal
No signs of meningeal irritation 

Motor system  tone normal
Power right upper Limb 5/5
Right lower Limb 5/5
Left upper limb 4/5
Left lower limb4/5
   Prvisional diagnosis 
Chronic kidney disease  with Hypertension and diabetes.







,
ECG



HEMOGRAM 
Hb-8.1
TLC-7,100
Neutrophils 65%
Eosinophils 05%
Lymphocytes20%
Plc 3.28 lakhs
PCV   23.6 vol%
Mcv 79.5

HbsAg Rapid negative 
HiV negative 
CUE
Colour pale yellow 
Appearance clear 
Albumin+
Sugars nil
Pus cells 4 -5
Epithelial cells-3 -4


Serum electrolytes 
Sodium-147
Potassium 3.5
Chloride 101
Serum creatinine 7.9
Blood urea 57

 LFT
SGOT 20
SGPT 11
ALP 204
TP 4.0 
ALB 2.0 
A/G Ratio 1.0
 Ultrasound report
B/L grade 1 RPD
Mild ascites
Provisional diagnosis 
AKI on CKD with Hypertension and DM 2 and cVA
Treatment
 1.Fluid restriction < 1.5 l/day
2 salt restriction <2.4gm / day
3.Inj Lasix 40mg Iv/BD
8am nd 4pm I'd sbp >110 mmhg
4.tab CINOD 10 mg po/BD
5.Tab Nodosis 50 mg po//BD
6.Tab Shelcal po/oD
7.Ecospirin AV 
8.GRBs 6th holy premeal
9.inj hai s/c 
10 monitor Vitals
11 .i/o charting

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