A 58 year old male with CKD on MHD

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 OCTOBER 21, 2021

This is an online e log book to discuss our patient identified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient problems through a series of inputs from available global online community of experts with a aim to solve those patients clinical problem with collective current best evidence based inputs.This blog also reflects my patient centered online learning portfolio and valuable inputs on the comments box is welcome.I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation.

K.TEJA SREE , ROLL NO:54 ,  9th SEM

CASE

A 58 year old male stone crushers by occupation came to the OPD with chief complaints of 

edema of left upper limb since 4 months. 

and came for dialysis.

HOPI :

Patient was apparently asymptomatic 4 years back. Then he developed giddiness for which he went to the local hospital and found out to be having High BP so detected as hypertension and from then he was on medication for hypertension.

2years back he had B/L pedal edema for which he came to the hospital and diagnosed as renal failure and initiated dialysis weekly twice. Dialysis started since 2019.

now he came for re-admission and complaints of edema of the left upper limb since 4months.


PAST HISTORY:

known case of hypertension since 4 years

  • medication on - Tab NICARDIA 1mg 
                             -Tab ARKAMINE 0.1mg

not a known case of diabtes, CAD, TB, Thyroid.

PERSONAL HISTORY:

Appetite : Normal

Diet : mixed

Bladder & bowel : regular

Sleep :adequate

no allergies and addictions

FAMILY HISTORY:

insignificant

GENERAL EXAMINATION

Patient is conscious, cooperative and coherent 
Well oriented to time, place and person
He is moderately built and moderately nourished.

He was examined after taking consent

  • Pallor  : absent
  • Icterus  : absent
  • Cyanosis : absent
  • Clubbing  : absent
  • Lymphadenopathy  : absent
  • Edema  :  absent

Vitals

  • Pulse rate  : 82bpm
  • Bp  : 130/70mmhg
  • Temperature : afebrile
  • Respiratory rate  : 24cpm
  • SpO2  : 98% at room air
  • GRBS : 126mg%

        SYSTEMIC EXAMINATION

  • RESPIRATORY SYSTEM

            -position of trachea: central

            - vesicular breath sounds                                                            

  • CARDIOVASCULAR SYSTEM   : S1, S2 heard and no thrills and no murmurs

  • PER ABDOMEN : soft non tender non distended.
  • CNS: higher motor functions are intact.

INVESTIGATIONS:

  • ultasound report on 20/10/2021






  • On 21/10/2021










  • On 22/10/2021
       - on dialysis 

  • On 23/10/2021
        - discharged 

PROVISIONAL DIAGNOSIS:
Chronic kidney disease on MHD

TREATMENT:
  • Fluid restriction <1.5L/day
  • Salt restriction <2.4L/day
  • T.Lasix 40mg PO/OD
  • T.Nicardia 10mg PO/TID
  • T.Shelcal CT po/od 
  • T.Nodosis 500 mg 
  • T.Bio-P3 0.25mg Po/OD 
  • INJ erythropoietin 4000 units weekly once














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