A case of CKD






















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 patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.”

A 64 yr old male who is a resident of nalgonda farmer by occupation came to the opd with the chief complaint of NO URINATION SINCE 3 days . 

HISTORY OF PRESENTING  ILLNESS

Patient was apparently asymptomatic 4 years back 
Later He developed  PAIN ABDOMEN  and TIGHTNESS 
and came to hospital for which he was diagnosed as having RENAL CALICULI and underwent Percutaneous nephrostomy 
in our hospital and later discharged . Later he developed GENERALISED WEAKNESS and DIZZINESS  for which he was diagnosed as DIABETES MELLITUS TYPE 2 and HYPERTENSION 2 years ago. On irregular medication 2 yrs back ( 2020 Nov )  on being unresponsive and was in ICU for 4-5 days and diagnosed to be hypoglycaemic and creatinine is 5.94 , denied for dialysis and discharged. Pedal edema was on and off and no decreased urine output , no hematuria . 

Fever associated with loose stools 10 days back , with decreased urine output for 1 day and anuria for 3 days  taken to the hospital and underwent 4 sessions of hemodialysis and came here for hemodialysis . 


                        
                          
                           
        
PAST HISTORY 

2 years ago he was diagnosed as having RENAL CALICULI and underwent PCN . 

K/C/O Diabetes mellitus since 2 years 

K/C/O Hypertension since 2 years 
N/K/C/O Asthma , Tuberculosis , epilepsy 

PERSONAL HISTORY 

Appetite - lost 
Eggetarian 
He has diarrhoea 
Micturition - abnormal ( Anuria )
 HABITS 
Alcohol- occasionally 
Tobacco - smoking chutta 




GENERAL EXAMINATION 

Pallor - Present 
Icterus - absent 
Cyanosis- absent 
Clubbing- absent 
Lymphadenopathy- absent 
Edema - present ( Anasarca ) 
             
               
VITALS : 

Temperature – 101°F 
Pulse rate –106 per min 
BP –160/90 
Respiration rate –
GRBS – 177mg % 
SPO - 96 percent
GRBS - 177mg%

SYSTEMIC EXAMINATION 
    CVS 
No Thrills 
Cardiac sounds S1,S2+
No murmurs 

RESPIRATORY SYSTEM 

Dyspnoea - present 
Wheeze - absent 
Position of trachea - central 
Breath sounds are vesicular

ABDOMINAL EXAMINATION 

Abdomen is obese 
No Tenderness 
No palpable mass 
Hernial orifices normal 
No free fluid 
No bruits 
Liver is not palpable 
Spleen is not palpable 
Bowel sounds heard 

CNS 
 Conscious
Speech is normal 
Signs of meningeal irritation- no neck stiffness
                                                 Kernings sign negative 
Cerebral signs - No finger nose in coordination 
                           No knee-heel in coordination 

PROVISIONAL DIAGNOSIS 
   Chronic renal failure with  
T2 DM and HTN 

Investigations 

       
         
    
    
  ULTRASOUND  
   
    
  

       

    
       
           

             
      
     
     
      
    
    
     


   TREATMENT
    1)salt restriction< 1 to 2 gm/day
2)fluid restriction < 2L/day
3) inj LASIX 40 mg IV BD 
4) tab .NICARDIA 10mg PO BD
5)tab.NODOSIS 500mg PO BD
6)tab. SHELCAL 500Mg PO OD
7)tab. OROFER-XT  PO OD
8)inj.erythropoetin 4000IU
9) haemodialysis , 
Antibiotics after culture


on 5/7/22 

BP: 100/70 mm of Hg 

PR:77 bpm 

RS: 18 Cpm 

CVS : SI and S2 Normal

CNS: NAD

per abdomen: soft and non tender

6/7/22

BP:90/60 Mm Hg

PR:86 bpm

C VS:SI,S2 +

C NS :NAD 

per abdomen:softand non tender

Treatment

Inj Lasix40mg IV Bd

Tab. Nicardia

T. Nodosis

T. Shelcal 

T. Orofor

T. Dolo

7/7 / 22 

BP:110/60 mm Hg

PR:80 bpm

C V S :SI,S2 +

CN S:NAD

per abdomen:soft and nontender

Treatment

Inj Lasix 

Tab. Nicardia

T. Nodosis

T. Shelcal

T. Orofer

T.Dolo 








Comments

Post a Comment

Popular posts from this blog

70M ALTERED SENSORIUM ET TUBE INSITU

Image
  70 year male was bought to Casuality in an intubated state HOPI: Pt is apparently asymptomatic until  2 days ago then he developed sudden onset of abdominal discomfort  and SOB after dinner. Patient was taken to nearby hospital in altered sensorium and was found Grbs-30 mg/dl . patient was intubated i/v/o poor GCS-5/15 and was bought to our hospital for further management with ET tube in situ PAST HISTORY: H/O Right inguinal surgery on 15/09/23 K/c/o hypertension since 12 yrs( on unknown medication) K/c/o Pulmonary Tuberculosis 30 years back( used ATT for 6 months) PERSONAL HISTORY: DIET :mixed APPETITE : Normal SLEEP: adequate  BOWEL AND BLADDER :Regular  Addictions : Patient was an Alcoholic and smoker 30 years ; stopped after diagnosed with Tuberculosis. FAMILY HISTORY:  N/K/C/O DM, Hypertension,Epilepsy, Asthma, Thyroid disorders. GENERAL EXAMINATION: Patient is on Mechanical ventilation. Dilated neck veins present. No Pallor,Icterus,clubbing,cynosis. VITALS: TEMP: 97.2 F BP: 160
Read more

29Y/M with CKD

Image
  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 : b/l pain in lower limbs upto knees since 20 days  B/l swelling in the leg since 20 days  HOPi : Pt was appently asymptomatic 3 yrs back then he developed sudden pain in right s
Read more

A 75 yr old female

Image
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 patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.” A 75 yr old female resident of Miryalaguda came to the opd witb the chief complaint of decreased urination and pedal edema  since 4 days  HISTORY OF PRESENT ILLNESS Pt was apparently symptomatic 4 days back then she developed severe itching due to mosquito bite following which she scratched that resulted in bleeding and she used hot water to wash the area then she had a feeling of something crawling on the leg . She has pedal edema since then  She has decreased urine o
Read more