AKI on CKD

23-10-22

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 45 year patient came to OPD with a chief complaint of swelling of both lower limbs , abdominal distension , reduced urine output.

History of illness : 

c/o swelling in both lower limbs - 15 days 

c/o abdominal distension - 5 days 

c/o decreased urine output - 15 days 

Past illness : 

c/o epigastric pain 

Swelling is pitting type progression gradual 

No H/O chest pain

H/O HTN on medication

No h/o DM / Asthma / epilepsy/TB 

PERSONAL HISTORY: 

Mixed diet 

Appetite normal

Bowel and bladder movements normal 

Sleep adequate

Alcohol consumption + 

Smoke + 

VITALS : 

Patient is afebrile 

BP : 210/120 mmg 

PR : 70 / min 

S1 S2 + BAE + 

Spo2 98% decreased RA 

Palpitation soft  

JVP raised

Pallor + 

INVESTIGATION : 

DIAGNOSIS : 

AKI on CKD / systemic HTN urgency 

MEDICATION :