A 60 year old Male with chronic kidney disease

 

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.

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.

A 60 year old male patient came to the opd with the

chief complaints of itching,weakness,loss of appetite since 5 days.

History of presenting illness 

patient was apparently asymptomatic 4 months back then he developed itching , loss of appetite,on and off vomitings -non bilious and contain food particles, fever on and off since 3 months.

 6 years back he went to hospital with complaints severe pain and restriction of movements in joints(started with the great toe and then the pip and dip joints and later progressed to other joints) where tests indicated increased levels of uric acid,se creatine levels---for this patient was given treatments (medications?) for gout.

4 months back patient started having complaints of loss of appetite,vomitings ,pain abdomen,back ache and went to hospital .on checking his se.creatine levels raised(6.2mg/dl) and had undergone his first dialysis at khammmam hospital. 

After dialysis patient had fever due to central line infection for which he was treated with antibiotics.

He had his last dialysis episode at gandhi 10 days back.

H/o- intermittent fever with chills and rigor since 3 months.

No h/0- burning micturition,decreased micturition,loin to groin pain

Past history 

He is a k/c/a of hypertension since 7 years(currently on METXL 25 mg)

No history of diabetes,tuberculosis,asthma,cad

PERSONAL HISTORY 

Routine activity:patient wakes up in the morning at 6 :30 am haves his breakfast and goes to the shop(he is a shopkeeper)and stays at shop till 1 then have lunch sleeps for 2-3 hrs and then goes back to work and stay there till    9 pm and takes dinner and goes to bed by 11.

Appetite-decreased since 4 months

Diet -mixed

Bowel and bladder movements-micturition normal,constipation since very long

Sleep -reduced since 4 months

Addictions-stopped 2 months back(previously occasional drinker used to take 180 ml)

FAMILY HISTORY -no similar complaints in family

GENERAL EXAMINATION 

 patient was conscious,coherant,and cooperative and well oriented to time place and person.

Vitals:- on admission 

Temp-afebrile

Pulse rate-83bpm

R rate-16 cpm

Blood pressure-140/90mm hg

Pallor-absent

Icterus - absent 

Cyanosis - absent 

Clubbing - absent 

Lymphadenopathy - absent 

SYSTEMIC EXAMINATION 

Cvs-s1 and s2 heard ,no murmurs heard

Respiratory system-normal vesicular breath sounds heard.

Cns-no focal neurological deficit

P/A-all quadrants moving equally with respiration, soft ,non tender

PROVISIONAL DIAGNOSIS - ckd with mhd

Investigations done on 1-11-22

Investigations on 2/12/22

  

                  Investigations on 3/12/22

                 Investigations on 5/12/22

Dialysis done on 4/12/22

Hemodialysis chart:

Inj heparin-20000cc.        

VP -100

Blood flow-180

TMP-120

RO water flow-500

BP-60/50

PULSE: 116

TEMP:98.6

GRBS:161

TREATMENT 

1.Tab. lasix 40 mg po b.d

2.T MET-XL 25 mg po   ,o.d

3.T NODOSIS 500 mgpo,b.d

4. T OROFER -XT  po o.d

5 SHELCAL po, o.d

6 Inj erythropoietin 5000IU ,SC weekly once

7 inj Iron sucrose 100 mg +100ml/NS IV OD weekly once