28Y/M with CKD
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Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
This E-blog also reflects my patient's centred online learning portfolio.
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 a diagnosis and treatment plan.
28 year old male patient came to casuality with chief complaint of decreased urine output since 3 days, bilateral pedal edema (pitting type) since 3 days and the patient mentioned that swelling was due to delay in hemodialysis.
The patient also had shortness of breath.
HISTORY OF PRESENT ILLNESS:
28 year old male , completed btech 5 years ago is undergoing haemodialysis in our hospital (10 times per month) since 3 years.
K/c/o CKD on MHD.
HISTORY OF PAST ILLNESS:
Patient was apparently asymptomatic 3 years back and then suddenly he had vomitings ( non blood stained ,containing food and water) 3yrs back for which he visited some private hospital and there he got diagnosed with high BP - 170 mmhg and had been using antihypertensive drugs since then.He then noticed decreased urine output.
Later after few days, he developed shortness of breath grade 4 NYHA and immediately started haemodialysis.He had 6 hemodialysis sessions at some private hospital. Since then he's been coming to our hospital to get hemodialysis done twice every week.
2years back the patient also had pulmonary Koch for which he took ATT for 6 months.
Patient has anemia and had blood transfusions about 1 year back.
K/c/o Hypertension since 3 years and is on medication.
Not a k/c/o diabetesmellitus
k/c/o of pulmonary TB.
PERSON HISTORY
Diet -
Appetite - decreased
Sleep - adequate
Bowel movements : regular .
Bladder movements : decreased urine output.
No addictions.
GENERAL EXAMINATION :
patient is conscious, coherent, coperative
No history of cyanosis, clubbing, malnutrition,icterus, lymphadenopathy,pallor.
Pedal edema is present.
Vitals:
Temp- 97.7 F
PR- 84
RR-18
BP-140/90mm of Hg
Systemic examination :
CVS: S1,S2 heard ,no murmurs.
Respiratory :no abnormalities detected.
Cns: no abnormalities detected.
DIAGNOSIS:
CKD on MHD with antihypertensives.
Treatment:
Fluid restriction (<1.5 l/day)
Salt restriction (<2 g/day)
T. Nicardia 20 MG PO BD
INJ· LASIX 40 mg IV/ TID.
T. SHELCAL-CT PO OD
T. OROFER-XR PO OD
T. NODOSIS 500 MG PO BD
T.ARKAMIN PO/TID
Monitor vitals
Grbs 6th hourly
INJ. ERYTHROPOIETIN 4000 U ONCE WEEKLY.
