Case history

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 patient's clinical problems with collective current best evidence based inputs. 

 65 year old male patient came to OPD with chief complaint 

shortness of breath  since 1 month 
 bilateral pedal edem and complain of decreased urine output since 2 months 

 decreased appetite

HISTORY OF PRESENT ILLNESS 
65 year old male who is daily labour by occupation 
 was apparently asymptomatic 14 years back doing all his routine activities and then he met with an accident  and developed  low back ache for which he was  treated for six days and then discharged .then he noticed continuously back ache for which he took NSAIDS for 10 years in nearby hospital
Two years back he noticed bilateral pedal edema and went to local hospital and treated .
2months back he noticed decreased urine output
Since 1 month  he complain of shortness of breath

PAST HISTORY 
K/c/o Hypertension since 1month 
Not a k/c/o diabetesmellitus

PERSON HISTORY 
Diet - mixed 
Appetite - decreased
Sleep - adequate 
Bowel movements : regular .
Bladder movements : decreased urine output

GENERAL EXAMINATION 
patient is conscious, coherent, coperative 
No history of cyanosis, clubbing, lymphadenopathy
Pedal edema is present 
Pallor is present 

Vitals:
Temp- 97.7 F
PR- 112
RR-20
BP-140/80mm of Hg

Systemic examination 

CVS: S1,S2 heard ,no murmurs  
Respiratory : B/L air entry, + NVBS+
P/A : soft non tender
Cns: no abnormalitys detected 

DIAGNOSIS:NSAIDS INDUCED  WITH CKD WITH METABOLIC ACIDOSIS WITH HTN(1MONTH)


Investigation 









Lumbo sacral x-ray

Treatment:
Fluid restriction (<1l/day)

Salt restriction (<2g/day)
INJ· LASIX 40 mg IV/ TID.

T. NODOSIS 500 MG PO BD

T. OROFER-XR PO OD

T. SHELCAL-CT PO OD

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