A 68 year old male with CKD on MHD


A 68year old male with CKD on MHD

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.
 

CASE PRESENTATION


A 68year old male came to the OPD with the chief complaints of
1. Shortness of breath since 7 days
2.Pedal edema since 7 days.

HISTORY OF PRESENTING ILLNESS


Patient was apparently asymptomatic 1 week back and presented with symptoms of 

Shortness of breath - grade 4
Pedal edema - on and off.

There is no h/o decreased urinary output, chest pain, palpitations and orthopnea.

HISTORY OF PAST ILLNESS

Patient is not a known case of hypertension, diabetes mellitus, asthma, tuberculosis and epilepsy.

There is h/o of a session of hemodialysis for SOB 2years back and discharged on medical treatment.

H/o NSAIDS abuse.


PERSONAL HISTORY


Appetite - Normal

Diet - Mixed 

Bowel and bladder - Normal

Sleep - Normal

No known allergies

No addictions.

FAMILY HISTORY 

Not significant

GENERAL EXAMINATION


Patient is conscious, coherent and co operative.
Well oriented to time, place and person.
 
Patient is moderately built and well nourished.

Pallor - Absent 
Icterus - Absent
Clubbing - Absent
Cyanosis - Absent 
Pedal edema - Present
Lymphadenopathy - Absent
 

VITALS 


Temperature - 98.4 F 
BP - 130/90 mm/Hg
Pulse rate - 84/min 
Respiratory rate -  24 cpm
SpO2 - 98%
GRBS - 126 mg%

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM 

S1,S2 heard
No murmurs 

RESPIRATORY SYSTEM 

Vesicular breath sounds
Central position of trachea
No Wheeze 
No Dyspnea

ABDOMEN

Scaphoid shaped abdomen
No tenderness and palpable mass
No bruits 
No free fluid
Liver - Not palpable
Spleen - Not palpable

CENTRAL NERVOUS SYSTEM 

Conscious 
Normal speech
Cranial nerves intact 
Normal sensory and motor system
Kernick's sign - Normal 
Neck stiffness - Absent  
 
REFLEXES - Normal

INVESTIGATIONS 


             COMPLETE URINE EXAMINATION


COMPLETE BLOOD PICTURE


                       LIVER FUNCTION TEST


SERUM IRON

 
RFT 

               
                     RANDOM BLOOD SUGAR  


HIV 


                    ANTI HCV ANTIBODIES


                          HEPATITIS - B


                           BLOOD GROUP


                                    ECG





PROVISIONAL DIAGNOSIS - CKD ON MHD


PLAN OF CARE - DIALYSIS

TREATMENT - 


Fluid restriction - <1.5 lt/day
Salt restriction - <2 gm/day
Tab. Nodosis - 500mg BD, PO
Tab. Livogen-Z BD,PO
Tab. Bio D3 - 0.25mg PO, OD
Tab. Ultracet I2 QID
Inj. Erythropoietin 4000 IU/SC weekly once
Tab. Shelcal - PO, BD



 

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