45 yr old male with CKD

CASE BLOG 



This is an online E-log to discuss our patient’s de-identified health data shared after taking hi/her/guardian’s 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 patients clinical problems with collective current best evidence based inputs. 
This E-log also reflects my patient centered online learning portfolio and your valuable inputs on comment box are welcome. 
I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis” to develop my competence in reading and comprehending clinical data including history, clinical findings and come up with diagnosis and treatment plan. 
The patient and the attenders have been adequately informed about the documentation and privacy of the patient. No identifiers shall be revealed throughout this presentation.




45 yr old male with ckd


Chief complaints::  A   45 year old man came to the casualty complaining of  shortness of breath since 2 days.

History of present illness:::

..He was apparently asymptomatic six years ago, then he had an episode of fever for which was admitted to the hospital.
. He was diagnosed with malaria.
.He was diagnosed with Diabetes Mellitus as well.
Then, 3 years ago, he had an another episode of fever for which he consulted a physician 
He was found to have Viral Pyrexia and was diagnosed with Hypertension.
Then around 1 year ago , one morning he had an episode of weakness of the right arm for which he was advised to undergo physiotherapy. 
After 6 months of physiotherapy, the family thought he might get dependent on it so discountined.

he came to the casualty with complaints of generalised swelling and shortness of breath since 2 days.
Which was insidious in.onset gradually progressive from grade 2 to 3 more common while eating
He was diagnosed with Acute Kidney Injury with Serim Creatinine value being 9.
He is undergoing regular Hemodialysis since then.
His last dialysis was on 18 February, 2022

Past history::

No history of similar complaints in past
H/o diabetes mellitus since 6yrs
H/o hypertension since 3yrs
H/o hypothyroidism since 3yrs

No h/o Tuberculosis,epilepsy,coronary artery diseases

Personal history:::

Appetite:normal
Diet:mixed
Bowel and bladder:regular
Sleep: adequate
Addictions::occasional alcoholand toddy drinker

Family history::
Not significant

Treatment.history::
Tab.metxl 50
Tab.Thyronorm 50mcg
Inj.insulin 10units bd

General examination
...Patient was consious coherent and cooperative 
..Consent taken
..Built: moderate
..Nourishment:moderate

No signs of icterus,cyanosis,koilonychia ,generalized LYMPHADENOPATHY
Pallor present


Vitals::
Temperature - Afebrile
BP - 110/80mm Hg
PR - 82bpm
RR - 18/min
SpO2 - 99% at room air

Systemic examination:::

Respiratory system..

Shape of chest..b/l symmetrical
Trachea..central
Normal vesicular breath sounds heard
No wheeze


Cardio vascular system::

 S1 S2 present
No added.murmurs

Perabdomen::

soft, non tender, obese with Abdominal distension
No tenderness
No palpable mass
Liver ,spleen non palpable
No fluid thrill 

Central nervous system::

Consious
Speech normal
Nonneck stiffness
Kerning sign .negative
Reflexes..normal


Investigations::

RFT :
Urea - 56mg/dl
Creatinine - 6.8mg/dl
Uric acid - 4.9mg/dl
Na - 143
K - 3.5
Cl - 93

LFT :
TB - 0.55mg/dl
DB - 0.16mg/dl
SGOT - 17
SGPT - 10
ALP - 210
Albumin - 3.2gm/dl
Total proteins..6.6gm/dl

Serology - Hiv,HBSAg  ..NegativeNegative

ECG:





Provisional Diagnosis : CKD on MHD

Treatment::
Tab.cilindipine od
Tab.Metxl 50 od
Tab torsemide od
Tab orofer XT od
Tab sodium bicarbonate

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