37yrs old man with renal failure.

 

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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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 

Chief complaints:

A 37yrs old male who is auto driver came to the opd with chief complaints of Decreased urine output since 3wks.

History of presenting illness:

Patient was apparently asymptomatic 4 1/2 years back then he developed lower back pain which was continuous ,non radiating. For which he went to hospital and diagnosed with renal disease for which he treated conservatively with medication and dialysis for 2 times.

For three years he was alright then 1 1/2 year back he had a complaint of frothy urine and SOB and he developed lower back pain which is not relieved with medication.so, he was admitted to our hospital from then he is undergoing dialysis twice a week.

He developed AV fistula at left below one year back.

Past history:

K/C/O Hypertension since 1yr

           Diabetes since 1yr

N/K/C/O Asthma,Tuberculosis,epilepsy.

Personal history:

Diet : Mixed 

Appetite : Decreased 

Sleep : Disturbed

Bowel moments :Regular

Bladder -decreased urine output 

Addictions:chronic alcoholic since 10yrs.

Family History:

Not significant.

General physical examination:

Patient is conscious,coherent, cooperative to time,place and person.moderately built and moderately nourished.

Pallor-present

Icterus-absent

Cyanosis-absent

Clubbing-absent 

Lymphadenopathy-absent

Edema-absent

Vitals:

Temperature - 99.5*c

PR :- 72bpm

RR :-20cpm

BP :- 130/90mm Hg

SPO2 :- 95%

GRBS :-246mg/dl

Systemic examination:

CVS-S1S2 heard no murmurs 

RS-BAE+

CNS-NFND

P/A-soft, non tenderness.

Investigations:

Provisional Diagnosis:

Chronic kidney disease on MHD.

31/8/22

Treatment:

Inj 25%D iv stat

Inj lasix 40mg iv bd

Tab Nicardia 10mg po bd

Syp potchlar 15ml in 100ml of water po TID

Tab nosodic 500mg po bd

Tab shelac 500mg po od 

Inj paracetamol 1mg iv stat.

1/9/22

Patient is conscious,coherent,cooperative.

Vitals:

Temperature - afebrile 

PR :- 86bpm

RR :-20cpm

BP :- 90/60mm Hg

GRBS-220mg/dl

Systemic examination:

CVS-S1S2 heard no murmurs 

RS-BAE+

CNS-NFND

P/A-soft, non tenderness.

Diagnosis:

Chronic kidney disease on MHD with hypertension,diabetes mellitus with recurrent hypoglycaemia.

Treatment:

Inv NS100ml iv bolus

Inj 25%D iv stat

Inj lasix 40mg iv bd

Tab Nicardia 10mg po bd

Syp potchlor 15ml in 100ml of water po TID

Tab nodosic 500mg po bd

Tab shelac 500mg po od 

Inj paracetamol 1mg iv stat.

2/9/22

Patient is conscious,coherent,cooperative.

Vitals:

Temperature - Afebrile

PR :- 90bpm

RR :-20cpm

BP :- 100/60mm Hg

Systemic examination:

CVS-S1S2 heard no murmurs 

RS-BAE+

CNS-NFND

P/A-soft, non tenderness.

Diagnosis:

Chronic kidney disease on MHD with hypertension,diabetes mellitus with recurrent hypoglycaemia.

Treatment:

Inj 25%D iv stat

Inj lasix 40mg iv bd

Syp potchlor 15ml in 100ml of water po TID

Tab nodosic 500mg po bd

Tab shelac 500mg po od.