60 YEAR OLD MALE WITH CKD
This is an online e-log book to discuss our patient de-identified health data shared after taking his / her / guardian's signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.
This E blog also reflects my patient -centered online learning portfolio and your valuable input in the comment box is welcome.
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 coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.
CHIEF COMPLAINTS :
A 60 year old male resident of kodada presented with chief complaints of
Vomiting on and off and decreased appetite since 4months.
Fever with chills on and off since 3 months.
Generalized itching,weakness,loss of appetite 6 days back.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 6 years back and then he developed severe pain and restriction of movements in joints
(started with the great toe and then the pip and dip joints and later progressed to other joints)
and had migrating joint pains and was diagnosed as gout in their regional hospital and was found that creatinine was increased, he used allopathy medication and ayurvedic medication for gout, he was on medication ( ?no records) for kidney problem for few years and stopped,
4 months back he developed generalized itching all over the body, anorexia, epigastric pain, vomiting which is non billious with food particles in it and he went to regional hospital where he was diagnosed as CKD creatinine (6.2 mg/dl) and underwent 2 sessions of dialysis and he developed infection after dialysis (central line induced) and he was admitted in icu for one day and treated,
he also had h/o of low grade fever since one month with chills and rigors since one month which is continuous subsided on using medication, h/o of constipation since many years, dry cough since 2 months, itching subsided after dialysis and recurrent itching episodes were present for which he used medication and it got subsided ,
since one week he is having diarrhea, anorexia, weakness and admitted .in our hospital and he is on medication (?)of ckd since 6 days and
No H/O burning micturition and decreased micturition, pedal oedema and
he wa admitted for dialysis and had dialysis on 4/12/22 and 6/12/22
PAST HISTORY:
Patient is hypertensive since 7 years and not on regular medication.
Not a known case of diabetes
No h/o of seizures, tb, asthma, leprosy.
3 months back underwent dialysis at khammam private hospital.
H/o itching on neck region and chin area and took medication and got subsided 3 months back
PERSONAL HISTORY:
Appetite- Decreased since 4 months
Diet -mixed
Bowel and bladder movements-micturition normal , constipation
Sleep -reduced since 4 months
Addictions-stopped 2 months back(previously occasional drinker used to take 180 ml)
Patient wakes up around 7am in the morning and gets fresh up and takes breakfast around 9am and stays at home, currently not working ( in the past , grocery storekeeper) and will have lunch at 1pm and takes rest and in the evening he will have dinner and goes to bed at around 9pm.
Family history: father has history of joint pains
Drug history :
no drug allergies and food allergies
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative. moderately built and nourished.
Pallor- present
Icterus- absent
Clubbing- absent
Generalised lymphadenopathy-absent
Edema-absent
Vitals:
Vitals:- on admission
Date: 1/12. 2/12. 3/12. 4/12. 5/12
Temp- 98.6. 98.6. 98.4. 98.4. 98.4
PR - 83bpm. 82bpm. 82bpm. 82bpm. 82
RR- 16 cpm. 18cpm. 17cpm. 16cpm. 16
BP- 140/90. 130/80. 110/70. 110/70. 110/70
6/12/22
Temperature- 98.3F
Pulse rate-86bpm regular, normal in volume
Respiratory rate- 18cpm
Blood pressure -120/80 mmhg
Spo2- 98%at room air
SYSTEMIC EXAMINATION:
Cardiovascular system:
S1 and S2 heard no murmurs heard
Central nervous system:
No focal neurological deficit,
cranial nerves intact.
Patient is concious coherent.
Motor
Tone- normal
Power- normal
Cerebellar functions-normal
Respiratory system:
Bilateral air entry-present ,Normal vesicular breath sounds-heard
Abdominal examination:
soft and non tender, No Hepatomegaly , spleen is not palpable
ECG
Hemogram:
Investigations on 2/12/22
Dialysis done on 4/12/22
Hemodialysis chart:
Inj heparin-20000cc.
VP -100
Blood flow-180
TMP-120
RO water flow-500
BP-60/50
PULSE: 116
TEMP:98.6
GRBS:161
Dialysis done on 6/12/22
Hemodialysis chart:
Inj heparin-20000cc.
VP -100
Blood flow-180
TMP-120
RO water flow-500
BP-65/52
PULSE: 110
TEMP:98.6
GRBS:161
PROVISIONAL DIAGNOSIS:
Chronic kidney disease on MHD
? secondary to NSAID abuse
Treatment- given since 1/12/22 to 5/12/22
1.Tab. lasix 40 mg po b.d
2.T MET-XL 25 mg po ,o.d
3.T NODOSIS 500 mgpo,b.d
4. T OROFER -XT po o.d
5 SHELCAL po, o.d
6 Inj erythropoietin 5000IU ,SC weekly once
7 inj Iron sucrose 100 mg +100ml/NS IV OD weekly once
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