45 year old male with legs pain, bilateral pedal edema, facial puffiness and lower backache.

45 year old male with legs pain, bilateral pedal edema,facial puffiness and lowerback ache.

This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome. 

Date of admission: 14-01-2023.

Chief complaint: A 45 year old male patient ,auto driver by occupation, resident of bhattugudam came to the casuality with the chief complaints of legs pain since 10 days , bilateral pedal edema, facial puffiness and lower back ache since 10 days.

HOPI:
Patient was apparently aasymptomatic 10 days back then he developed left foot pain and went to miryalguda local hospital for a checkup, necessary investigations were done and told that he had kidney issue, he applied ointment ( unknown) for pain relief. 8 days later he started having pain in both the lower limbs, associated with calf stiffness, non radiating, and back pain. He had bilateral pedal edema and facial puffiness during the episode and 
Decreased urine output.
No h/o burning micturition
No h/o vomitings
No h/o diarrhoea or constipation
No h/o fever
No h/o weight loss

History of past illness:
-No similar complaints in the past.
N/k/c/o  HTN, DM, CAD, TB, Epilepsy, Asthma.

PERSONAL HISTORY:
-Diet-Mixed
-Appetite - adequate 
-Sleep-disturbed.
-Bowel and Bladder movements -Regular
-Habits : consumes alcohol regularly since 20 years(75ml) per day.
Smokes beedi 1 pack(8-10) per day.

FAMILY HISTORY:
No known significant Family history

General examination:
-Patient was examined after taking his consent.
-Patient was conscious, coherent, cooperative, well oriented to time place and person, well nourished and well built.
-Pallor- Absent
-Icterus- absent
-Clubbing- absent
-Cyanosis- absent
-Lymphadenopathy - absent
-Edema- absent.

Vitals:
-Temperature: afebrile
-Blood pressure:110/80mmhg
-Pulse rate:98 bpm.
-Respiratory rate:22 cpm

Systemic examination:
GIT examination:
-Oral cavity- No dental caries,  stains present.
- Obese
- No visible pulsations/engorged veins/scars/sinuses
-Abdomen is soft , non tender , no organomegaly , no free fluid
- Bowel sounds present

Respiratory examination:
-Chest is bilaterally symmetrical.
-Movements with respiration are equal on both the sides.
-Trachea appears to be in center.
-No kyphoscoliosis.
-Normal Vesicular breath sounds are heard.

Cardiovascular examination:
- Elliptical & bilaterally symmetrical chest
- No visible pulsations/engorgedveins/scars/sinuses on the chest wall
- Apex beat palpable at 5th intercostal space medial to midclavicular line 
- S1 , S2 heard
- No murmurs.

CNS examination:
-No focal neurological deficets .
-Speech is normal.
-Memory is intact.
-Higher mental functions -intact.

Provisional diagnosis:
-Renal failure.

Investigations:
On 14-01-2023.
Serum creatinine:
Urine protein/creatinine ratio.
Liver function test(LFT).
BLOOD UREA.
Complete urine examination (CUE).
HEMOGRAM.
on 15-01-2023

On 16-01-2023
On 17-01-2023

ECG
USG abdomen:
B/l shrunken kidneys.

Final diagnosis: Chronic kidney disease.

Treatment:
Hemodialysis advised.
Tab lasix 20mg pd/BP
Tab vomikind
Syp ascoril 10 ml po/tld
Tab sobosis forie 1g/ tid.

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