40 year old male with CKD on MHD
Oct 27,2021.
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•I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation.
•A 40 yr old male came to the opd with
Chief complaints:-
-pedal edema since 3 months
-Decreased urine output since 3 months
-Back pain since 2 months
-Shortness of breath since 3 days
••The patient used to work as a farmer and his daily routine consisted of him waking up at 6am and he goes to do agricultural work, his average work day ended at 7pm after which he takes rest.••
History of present illness:-
Patient was apparently asymptomatic 3 months back after which he developed
-pedal edema since 3 months uptil ankle which is on and off and it subsided on rest and it is associated with facial puffiness.
-Decreased urine output since 3 months.
-Back pain since 2 months which is dragging type and of moderate in severity.Aggravated on daily activities and relieved on medication.
-Shortness of breath since 3 days -Grade 2.
Cough since 3 days.
•Hemodialysis started on 15/10/2021.
4 sessions of hemodialysis done.
Past History:
No similar complaints in the past.
Not a known case of DM,HTN,TB and Asthma.
Family History:
Not significant
Personal History:
occupation : farmer
diet :mixed
appetite : decreased
bowels : regular
micturition :decreased urine output
No known allergies
No addictions
General Examination:-
patient was conscious , coherent and coherent and examined in a well lit room
VITALS
pulse rate :84bpm
respiratory rate : 24/min
BP: 130/70 mmHg
Temperature : Afebrile
GRBS :136mg/dl
SpO2: 98% at room temperature
Physical examination
Pallor : not present
icterus : not present
cyanosis : not present
clubbing : not present
lymphadenopathy : not present
pedal edema : present , pitting type
•Clinical Images:-
Systemic examination:-
-CVS
S1 and S2 are heard
no thrills and no murmurs
-Respiratory
vesicular breath sounds heard
trachea is in central position
no wheezing
Dyspnoea-grade 4.
-Abdomen
obese shaped abdomen
no tenderness
no palpable mass
no hernial orifices
no free fluid
liver and spleen are not palpable
bowel sounds are heard
-CNS
Conscious and normal speech
normal gait
crainal nerves are normal
sensory system is normal
motor system is normal
Investigations:-
CBP:
Blood Urea:
Serum Creatinine:
Serum Electrolytes:
Provisional Diagnosis:-
Chronic Kidney Disease on MHD.
Treatment:-
On 26/10/2021:
On 27/10/2021:
On 28/10/2021:
1 session of hemodialysis done.
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