1601006043 SHORT CASE

 

40 y/o Male on Maintenance Hemodialysis

 This is an online E logbook to discuss our patient’s de-identified health data shared after taking his signed informed consent.

Here we discuss our individual patient’s problems through series of inputs from the global online community of experts with an aim to solve those patient’s clinical problems with collective current best evidence-based inputs.

This E-logbook reflects my patient-centered online learning portfolio. 

CHIEF COMPLAINT : 40 y/o male swelling of feet and difficulty in breathing since 3 days. 

PRESENT HISTORY : Pt was apparently alright 3 days ago
He had swelling of the feet which was insidious on onset, did not subside with rest.
Accompanied by insidious onset shortness of breath which is present even at rest because of which pt is confined to the bed.
No H/o fever / evening rise in temperature 
No h/o weight loss 
No h/o night time breathlessness /  increased difficulty with lying supine / chest pain 

PAST HISTORY : 
K/c/o HTN since 2 years 
K/c/o Calcemic Uremic Arteriolopathy 
Has been on maintenance hemodialysis since 2 years every once in 2 weeks

GENERAL EXAMINATION

Pt is conscious, coherent,  cooperative ; oriented to time place and person 
Moderately built and moderately nourished 
Pallor present 
Icterus, Cyanosis, Lymphadenopathy
B/L Pitting Pedal Edema up till ankle joint lasts around 1 minute 
No visible pulsations on the neck 




Vitals 
  • Afebrile
  • Pulse - 72 bpm
  • Resp rate - 16 cycles per min
  • BP - 140/100 mm hg 
SYSTEMIC EXAMINATION 

CVS - 
Apex at 5th ICS 
S1 S2 heard 
No murmurs 

Respiratory - 
B/L air entry present 
Trachea central
Vocal fremitus resonant and symmetrical 
Vesicular breath sounds 

Gastro-Intestinal
Scaphoid, soft non tender abdomen 
Hernial orifices normal 
No organomegaly 
Bowel sounds heard 

CNS
Conscious
HMF normal
Motor and Sensory systems Normal 

Provisional Diagnosis - 

40 y/o pt k/c/o HTN on biweekly dialysis with CUA with B/L Pedal Edema and Grade IV SOB

Investigations 
1. Hemogram 
2. RFT
3. LFT
4. Serology - HI, HbsAg, HCV
5. Chest x-ray
6. USG Abdomen 
7. ECG


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