A 54 year old male with chronic kidney disease

December 02, 2022

Note - This is an a online e log book to discuss our patient's 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 centred 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.

2nd December 2022

Manvi Sharma

Roll no 88 (2k18 batch)

CASE -

A 54 year old male came to OPD with chief complaints of -

bilateral pedal edema since 1 week

decreased urine output since 1 week

History of presenting illness -

The patient was apparently alright 5 years back then one day he developed fever which was sudden in onset. The fever was associated with other symptoms such as vomitings, generalized edema and increased perspiration.

For this he consulted the local hospital where he was diagnosed to have hypertension and is on regular medication since then. He was adviced to come to our hospital for dialysis as he was found to have deranged kidney function.

He visited our hospital and was advised four sessions of dialysis despite which his condition didn't improve.

Subsequently, he was started on regular hemodialysis sessions about 2 sessions per week since the last 5 years.

H/o bilateral pedal edema since 1 week and decreased urine output since 1 week.

H/o pain in the left hip region and back which developed suddenly and he is unable to walk since 5 days.

Past history -

10 years back he was diagnosed to have hypothyroidism and started taking medication after 1 year.

He is a k/c/o HTN since 5 years

Not a k/c/o DM , TB, asthma, epilepsy, CAD, CVA

No h/o any previous surgeries

Personal history -

Daily routine before 5 years -

He used to work as a supervisor at a paint shop. His routine comprised of waking up at 6 am and leaving for work at 7 am. He used to be back by 7 pm and spend time with family. He used to have 3 meals per day. He used to smoke 1-2 beedi per day and consume 100ml of alcohol per day from past 20 years.

Daily routine since last 5 years -

He stopped going for work. Now he just stays at home and goes for his weekly dialysis sessions. He takes only 1 - 2 meals per day. He has given up on his addictions due to his condition.

There is significant weight loss from 80 to 45 kgs.

Appetite - decreased

Diet - vegetarian

Bowel & bladder habits - reduced

Sleep - inadequate

Treatment history -

Since last 5 yrs on -

Tab Nicardia Retard 20mg

Tab Arkamin 100micrograms

Tab Lasix 40 mg

Tab Sobinid 500mg

Tab Calvic-D

Tab Calci

Since last 9 yrs on -

Tab Thyronorm 25 micrograms

Family history -

No significant family history

General physical examination -

The patient is conscious, coherent, cooperative and well oriented to time, place and person.

He is thin built and poorly nourished.

Pallor - present

Icterus - absent

Cyanosis - absent

Clubbing - absent

Lymphadenopathy - absent

B/l pitting type of pedal edema seen

B/l edema of the upper limbs more on left than right

AV fistula on left arm since 3 years

Vitals on admission -

Temperature - 98 F

PR - 88 BPM

RR - 16 CPM

BP - 140 / 90 mm Hg

Systemic examination -

CVS - S1, S2 heard,no murmurs

Respiratory system - trachea is central, all quadrants of chest moving equally with respiration, normal vesicular breath sounds are heard, no adventitious sounds heard

CNS - no focal neurological deficits

Abdominal system -

On inspection - abdomen is flat & symmetrical

Umbilcus is central and inverted

No scars, sinuses & engorged veins seen.

All 9 regions of abdomen are equally moving with respiration

On palpation - abdomen is soft and non tender

On percussion - no shifting dullness, no fluid thrill

On auscultation - normal bowel sounds are heard

Investigations -

On 30-11-22

Hemogram