47 yr male with CKD

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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 clinical problems with collective current best evidence based inputs.

47 YR MALE WITH ? CKD ( DIABETIC NEPHROPATHY) , ? HEART FAILURE
47 year old male ,auto driver by occupation , came to the OPD with the chief complaints of

Pedal edema & Facial puffiness since 6 days

Shortness of breath since 6days 

Increased since past 3 days

Decreased urine output since 3 days

History of Presenting illness - 
Patient was apparently asymptomatic 8 years ago

8 years ago - During a regular checkup he was found to be Hypertensive

6 years ago - He had complaints of generalized weakness and weight loss 
He was diagnosed to be diabetic

5 years ago - He was diagnosed with Acute pancreatitis

6 days back - Pt developed pedal edema, progressed gradually to knees along with Facial puffiness

Shortness of breath since 6d 
Grade II-III progressed to Grade IV since 3 days along with orthopnea and PND 

Decreased urine output since 3d

Decreased appetite

No c/o chest pain, palpitations, giddiness ,fever, cold, cough, burning micturition. 

PAST HISTORY -
Known case of Hypertension since 8years on Tab Olmesartan 20mg OD

Diabetes mellitus since 6 yrs on Tab Glimy M2 OD

H/O Acute Pancreatitis 5 yrs ago

Not K/C/O TB, Epilepsy, Asthma, CAD.

Personal history
Appetite- Decreased
Bowel movement- Regular
History of alcohol intake stopped taking alcohol five years back. 
Smoking stopped 5 yrs ago

On examination
Pt is C/c/c
No Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy
Edema of feet + 

Vitals
Pr: 94bpm
Bp: 180/100
SpO2: 97% at RA
Temp - Afebrile
Grbs - 166 mg/dl

Systemic examination

CVS - S1,S2 +
RS - BAE + B/L ISA, IAA crepts +
CNS - NAD

Investigations
Serology - Negative
RBS - 105mg/dl

Provisional Diagnosis - ? CKD ( Diabetic Nephropathy) ; ? HEART FAILURE

Treatment

Fluid restriction (<1L/day)
Salt restriction (<2g/day)
Inj· LASIX 40 mg IV TID, if Sbp > 100 mmhg.
Inj. Pantop 40 mg IV/BD.
Inj. Actrapid + NPH s/c acc to GRBS
Tab. CARDACE 2.5mg - PO/BD
Tab. CARVEDIOL 3.125mg PO/OD.
Tab. ECOSPIRIN - 75mg PO/OD .
Tab. ATORVAS -10 mg HS.
O2 Inhalation SOS.
BP/PR charting 2nd hourly.
GRBS charting 6th hourly
Strict I/O charting.
Daily weight monitoring.

Clinical findings.
? Ascites 

Pedal edema 

Pallor


Investigations.
Chest X ray 

Complete urine examination

Hemogram

Liver function test

EKG

Serum creatinine

Serum electrolytes

Blood urea

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