Skip to main content

CKD on mhd

This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.

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. 


 A 32 year old male patient came to the OPD with chief complaints of decreased urine output, bilateral pedal edema, and shortness of breath.

HOPI: patient was apparently asymptomatic 1year back then he developed loss of consciousness for which he went to the local hospital, there he had noticed b/l pedal edema of pitting type. Patient also has pain in rt. Leg 6 months back for which he had operation.
- patient also had low urine output, burning micturition since 1 yr back.
- patient also has SOB.


Daily routine ;
he wakes up at 6am and takes his breakfast at 7:30am.which includes idli and chapathi. After breakfast he watches T.V . he takes his lunch at 11:00am. Which includes rice and dal. Then he sleeps for 2 hours. Then at 7:00pm he takes his dinner. Which includes rice and dal. And sleeps at 9:00pm.

PAST HISTORY:
K/c/o: hypertension since 5years.
And not a known case of DM,TB, EPILEPSY.

PERSONAL HISTORY:
diet mixed
Appetite normal
Sleep adequate
Bowel and bladder regular
Addictions:

EXAMINATION:
Patient was conscious, coherent, cooperative,well oriented to time ,place and person.
Pallor is seen
Icterus is absent
cyanosis absent
 clubbing absent
lymphadenopathy absent.

Temp- Afebrile (98.5f)
Bp- 140/90 mm hg
PR- 99 BPM
RR- cpm
Spo2-91%

Systemic examination: 
CVS: s1 and s2 are heard .no cardiac murmurs.

RS: dyspnea is present,no wheezing,trachea is central .
       Normal vesicular breath sounds are heard.

ABDOMEN :
Shape of abdomen is scaphoid. Abdomen is soft.
No palpable mass , no tenderness, no hernial orifices.

CNS : NAD
Treatment:
Salt restriction <3.4gm/day
Fluid restriction <1.4lit/day
TAB. lasix 40mg
TAB. Shelcal 
TAB. Nicardia 10mg
TAB. Drofer
TAB. Nodosis 500mg
Inj. Erythropoietin 4000IU
Provisional diagnosis : CKD on MHD


Investigation:
CBP:
RFT:
LFT:
COMPLETE UNRINE EXAMINATION:
HBsAg-rapid
Serum iron
Blood grouping and RH TYPE
ECG

Comments

Post a Comment

Popular posts from this blog

Image
70 year old male with  1)fever since 15 days 2)generalised weakness and body pains  in bilateral lower limbs since 10  days HOPI Pt was apparently asymptomatic 15 days back then had fever which high grade more during night time associated with chills and rigors it is intermittent not associated with cold , cough, vomitings , loose motions, abdominal pain, burning micturition , no h/o rash, hematuria, bleeding from gums For which he was taken to local rmp and  got treated for the same and diagnosed typhoid fever and reports from outside showing platelets of 85,000 Then he had generalised body weakness and  pains in bilateral lower limbs and lower back ache since 3days. Pt is unable to walk or stand without support since 3 days DAILY ROUTINE He wakes up at morning 6 does his daily routine and takes rice at 8:00-9:00am goes to work ( farmer)  and takes food at 1:00pm returns home at 5:00 pm and takes dinner at 8:00pm qnd goes to sleep PAST HISTORY   not a known case of HTN ,DM ,ASTHMA, EP
Read more

A 53 year old came to casuality with C/o pedal edema since 2 months. C/O SOB Since 1 day. C/O decreased urine output since 2 months.

Image
A 53 year old male came to casualty with chief  C/o pedal edema since 2 months C/O SOB Since 1 day C/O  decreased urine output since 2 months. History of presenting illness:- Patient was apparently alright 1 year back then  he developed  decreased urine output for which he went to hospital and  was diagnosed as chronic kidney disease and was on Conservative management.  Patient  developed decreased urine output since 2 months. No  Hesitancy, dribbling of urine. -History of pedal edema Since 2 months, pitting type upto knee. -History of SOB since 1 day; Grade -IV according to MMRC  , Orthopnea present, no   PND. No chest pain, no palpitations.  3. HISTORY OF PAST ILLNESS K/c/o Dm-ll Since 7 years on insulin K/c/o HTN Snce 1 year on CILNIDIPINE 10mg. No history of asthma ,tuberculosis ,epilepsy  Personal history:  Diet mixed  Appetite normal  Sleep Adequate Bowel are regular Bladder movements decreased output since 2 months. Addictions:  Alcohol - regular but stopped since 2 years Smokin
Read more

34 year old male with vomiting, hiccups and cough.

Image
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 welcaaome. 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. 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 i
Read more