A 69 year old male with CKD

7th March 2022
This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.
Chief complaint:
69 year old male farmer by occupation came  to OPD with a chief complaint of pedal edema since 10 days
History of present illness:
Patient was apparently asymptomatic 5 yrs ago.
Patient complained of decreased urine output and then diagnosed with bilateral pedal edema 6 months ago.
History of past illness:
Not a k/c/o diabetes, hypertension,tuberculosis, asthma.
PERSONAL HISTORY:

Appetite - Normal

Diet- mixed

Bowel movement- regular

No allergies

Sleep: adequate
GENERAL EXAMINATION:
patient is Conscious,coherent and cooperative 

-No pallor

-No icterus

-No lymphadenopathy

-No cyanosis

-No malnutrition

-No dehydration

-No clubbing of finger

-pedal edema is seen
Vitals: 
Temperature:Afebrile
Pulse rate:82bpm
Respiration rate:16cpm
Bp:110/80 mmHg
Spo:92%

SYSTEMIC EXAMINATION:

▪️CVS

- No thrills

- No cardiac murmurs

S1 & S2 sounds are heard

▪️ RESPIRATORY SYSTEM

-BAE present

▪️CNS

-HMF intact

INVESTIGATIONS:
Serology :negative
Provisional diagnosis:CKD
Treatment:
T.OROFER.XT PO/OD
T.NODOSIS 500 mg PO/BD
T.SHELCAL PO/OD


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