Chronic Kidney Disease

MEDICINE CASE DISCUSSION

This is 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 patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome

    Sai Kiran Gundabathuni
    Roll no: 157
    3rd semester

CASE PRESENTATION 

A 61 year male farmer by occupation came to OPD for hemodialysis.

COMPLAINTS AND DURATION 

Patient was apparently alright 3 years back with complaints of lower back pain went to local hospital found out to be having RENAL FAILURE , on medication for 2 years ( with baseline serum creatinine 3mg/dl) 
Then went to NIMS hospital on 08/09/2020 with complaints of anorexia , dyspepsia , insomnia found out to be having serum creatinine 2mg/dl, Dialysis was initiated and on MHD weekly twice 

HISTORY OF PRESENT ILLNESS :

On hemodialysis through radial AV fistula for 9 months.
Failed after 9 months
Tried Brachial AV fistula got failed 
Now getting dialysis through right femoral line on 16/10/2020

HISTORY OF PAST ILLNESS:

k/c/o HTN since 3 years on irregular medication

PERSONAL HISTORY :

married
Appetite - normal
Diet- mixed
Bowels- regular
Micturition- normal

 FAMILY HISTORY :

not significant

 GENERAL EXAMINATION:

Patient is conscious coherent and cooperative.
He is well oriented to time, place and person.
He is moderately built and well nourished.

VITALS :

Temp - 98.4 F
Pulse rate - 84 beats/ min
Respiration rate - 24 cycles/ min
BP - 130/70 mm Hg
SpO2- 98%

SYSTEMIC EXAMINATION:

A) CVS
    S1 and S2 are heard
    No cardiac murmurs
    No thrills found 
B) RESPIRATORY SYSTEM
     No dyspnoea 
     No wheezing
     Position of trachea is central
     Breath sounds vesicular
C) ABDOMEN
     Shape - scaphoid
     Liver and spleen non palpable
     Bowel sounds are heard
D) CNS 
      Normal

PROVISIONAL DIAGNOSIS

      CKD on MHD
       K/c/o HTN since 3 years 
       Dialysis started on 09/09/2020

INVESTIGATIONS:



FINAL DIAGNOSIS

    CKD on MHD
TREATMENT :
   1)fluid restriction < 1.5 lt/day
   2)Salt restriction  < 2gm/day
   3)Tab. LASIX 40mg × Po × BD
                    8am-4pm-×
   4)Tab. NODOSIS  500mg × Po × BD
                    8am-×-8pm
   5)Tab.BIO-P3  0.25 × Po × OD
                           ×-1-×
   6)Tab. SHELLAL CT 500mg × Po ×OD
                            ×- 1-x
    7) Inj. Erythropoietin 4000 IU s/c

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