24th august 2020

"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome "

A 44 year old male patient presented to opd with chief complaints of pedal edema, shortness of breathe and facial puffiness since 1 month. 

History of Present illness:

-Patient was apparently asymptomatic since one month back then develops pedal edema, shortness of breath and facial puffiness. 

-Now visited the casuality due to fever and chills, dry cough since the day before and shortness of breath grade 3 and 4.

History of past illness:

-There is history of hypertension since 2years.

-There is  history of covid 19 since 3months back and treated in home isolation. 

-History of chronic kidney disease and on medical management and done the hemodialysis for 5 sessions from 1 month.  

-There is no history of asthma, diabetes, tuberculosis. 

Treatment history:

-Medication for hypertension was taken.(Nifedipine since 1 and half years). 

-Blood transfusion. 

Personal history:

Diet-Mixed. 

Sleep-adequate. 

Apetite-lost. 

Bowel and bladder movements- Regular. 

Addictions- Alcohol intake occasionally . 

There is no history of allergies to known drugs. 

Family history:

No history of such similar complaints in the family. 

General examination

Patient was conscious, coherent and cooperative. 

Well oriented to time, place and person. 

-Physical examination:

Pallor- yes. 

Icterus-No. 

Cyanosis-No. 

Clubbing-No. 

Generalized lymphadenopathy-No. 

Moderately built and norished. 

Vitals:

         -Temperature-102°F

         -Pulse-104/min.

         - Respiratory count-32/min.

          -blood pressure-170/100mm of hg. 

          -spo2 at room air-98%

Systemic examination:

-Cardiovascular system- 

     Chest wall is bilateral symmetry. 

      S1 and S2 are heard. 

-Respiratory system-

      Bilateral airway

      Dyspnoea is present

      Position of trachea is central

      Normal vesicular breath sounds are heard

-Abdomen-

       Abdomen is soft and tender

       Bowel sounds are heard

-Central nervous system-

        Patient is conscious

        Reflexes are normal

         Speech is normal

Provisional diagnosis:

Chronic kidney disease on hepatic hemosiderosis in maintenance hemodialysis. 

Investigations:

Liver function test:

Blood urea:

Serum creatinine:

Serum electrolytes:

Treatment:

Tab. Lasix 40mg po/bd

Tab. Orofer XT po/bd.