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



 

Comments

Post a Comment

Popular posts from this blog

A 20 YEAR OLD MALE CAME WITH FEVER AND VOMITING

Image
This is an online E log book to discuss our patient's 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 available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. A 20 year old male driver came to opd wit complaints of  1) Fever since 2days  2) Vomiting since 6hrs HISTORY OF PRESENTING ILLNESS Patient was apparently asymptomatic 2 days back then he developed fever which is not associated with chills and rigors and relieved with medication. No diurnal variation. Vomiting since 6hrs with 3 episodes and content as food material, blood tinged, non bilious, non projectile. He skipped 1 dose on insulin yesterday evening. No h/o loose stools, pain
Read more

INTERNSHIP LEARNING ASSESSMENT

INTERNSHIP LEARNING EXPERIANCE PAJRs I created around 3 PAJR  groups and updated critical data about the patient like his ECG, Chestxray, 2D-Echo, Feverchart. PAJR mainly consists of blogs and soapnotes  SOAP NOTES Soap notes consist of complaints, Vitals, Diagnosis and Treatment of patient. FEVER CHART In medicine department my pgs taught me how to plot fever chart,importance of fever chart . PERIPHERALS I learnt - To d raw samples from radial and femoral artery. - Took ABG sample - Performed CPR - Secured multiple cannula - Inserted Foley’s catheters, condom catheter and Ryle’s tube - Monitored vitals of all patients either hourly. -Attended rounds for ICU and AMC cases. NEPHROLOGY AND WARD DUTY - Assisted  how to secure a central line  -  Give IV injections - Seen the complications of dialysis - Monitored the patients undergoing dialysis -  Observed multiple CKD cases requiring dialysis. PSYCHIATRY   - I learnt alot of cases about Schizophrenia, depression, OCD, Anxiety disorders. -
Read more

A 80 YEAR OLD MALE WITH AKI WITH DIABETIC NEPHROPATHY

Image
  This is an online E log book to discuss our patient's 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 available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. An 80-year-old male resident of Kamanpet was admitted with complaints of  1) Acute urinary retention for past 24 hrs. 2) Fecal retention for the past 24 hours. HISTORY OF PRESENTING ILLNESS The patient was apparently asymptomatic a month ago then he began experiencing bilateral lower limb and knee pain.  Patient experienced inability to defecate (accompanied by the absence of flatus) and urinate, along with shortness of breath since yesterday .  No H/o of fever, nausea, vomiting
Read more