65 year old male came for dialysis



 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.




This E blog also reflects my patient centered online learning portfolio and your valuable inputs on 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 come up with diagnosis and treatment plan.


A 65year old male  farmer by occupation came to opd with chief complaints of pedal edema

HOPI

Patient was apparently asymptomatic 10 years ago Then he got into an accident because of a cutter machine used in agriculture which caused upper hip injury.Then he was under conservative treatment.

 In early 2022 he had chief complaints of decreased appetite,decreased urine output and pedal edema.


He underwent dialys for 3 times in last 3 months.



Past history 

K/c/o Hypertension (1year)

 

Not a k/c/o diabetes,asthma,Epilepsy ,TB


PERSONAL HISTORY

Diet:Mixed 

Appetite:Normal 

Sleep: Adequate

Bowel and Bladder movements:Black colored stools at the time of presentation ,normal micturition.

No addictions .

No allergies.


FAMILY HISTORY

Not relevant


GENERAL EXAMINATION


Patient is coherent,conscious and cooperative .

Patient is well nourished.

No pallor, icterus, clubbing, cyanosis,lymphadenopathy,edema


Vitals

Blood pressure : 150/90 mm Hg

Pulse rate:87

Respiratory Rate:

Spo2 :97 percent

SYSTEMIC EXAMINATION:

Cardiovascular System: S1 and S2 heard.

No murmurs heard.

Respiratory system: vesicular breath sounds heard.

Position of Trachea: Central

Per abdomen:

Shape of abdomen: scaphoid

No tenderness

No organomegaly.

Bowel sounds not heard 

Central nervous system:

Conscious

Normal speech.


PROVISIONAL DIAGNOSIS 

Chronic Kidney Disease 


Investigations

Complete Blood picture 

GRBS

RFT
Serum iron


Treatment 


T.Lasix 4mg BD

T.Vodosis 500mg BD

T.Shelcol 500mg OD

T.Pan 40mg OD

Inj.ETO 4000 iv /once weekly 


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