39 year old male with CKD on maintainence hemodialysis

This is an online e log book to discuss our patient identified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient problems through a series of inputs from available global online community of experts with a aim to solve those patients clinical problem with collective current best evidence based inputs.This blog also reflects my patient centered online learning portfolio and valuable inputs on the comments box is welcome.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.


39yr old male who is farmer by occupation came to the hospital on 8/3/22 with chief complaints of:
 -pedal edema since 8/3/22 morning
- shortness of breath since 8/3/22 morning grade I

Presenting illness:
Patient was apparently asymptomatic 2yrs back.Then he developed pedal edema, facial puffiness, SOB for which he went to hospital in nalgonda where he was diagnosed with renal failure and hypertension and was put on dialysis and antihypertensive medication.
The patient was developing these symptoms on and off for which taking dialysis regularly.

Patient also complaints of reduced urine output 

On 8/3/22 he had
-Pedal edema which was insidious in onset and was of pitting type which was upto knee 

-SOB grade I which was sudden in onset and was not associated with orthopnea, PND, palpitations, chestpain

On 23/3/22 he again developed SOB which was grade IV(NYHA) and was associated with PND, orthopnea.
It was not associated with palpitations and chestpain.


PAST HISTORY

He is a known case of hypertension since 2yrs for which he is on regular medications
He is not a known case of DM, TB, Asthma, epilepsy.

PERSONAL HISTORY:

Diet:mixed
Appetite: reduced
Sleep: disturbed
Bowel : regular
Bladder: reduced urine output
Addictions: alcohol since 10yrs but stopped since 2yrs
No known drug or food allergies

FAMILY HISTORY

Not significant


GENERAL EXAMINATION
Pt is conscious ,coherent, cooperative moderately built,moderately nourished
Pallor present
No icterus, cyanosis, clubbing, generalised  lymphadenopathy no generalised edema
Vitals- 
Temp -afebrile
Pulse rate-78 bpm
Respiratory rate-22 cpm
Bp-130/90mm hg
Spo2- 92%

Systemic examination:
Inspection
No scars seen
No chest wall deformities
Spine normal
No visible pulsations

Palpation
Apical impulse felt at 5th ICS midclavicular line
No parasternal heaves or thrills present

Ausultation:
S1, S2 heard

Other system examinations:
RS: normal B/L air entry 
P/A: soft, non tender, no organomegaly
CNS: intact

INVESTIGATIONS:


PROVISIONAL DIAGNOSIS
chronic renal failure on maintainence hemodialysis

TREATMENT:
8/3/22
-Fluid restriction less than 1.5 L/day
-salt restriction less 2gm/day
-Tab. NODOSIS 500mg po/BD
-Tab lasix 40mg BD
-Tab orofer BD
-Tab shelcal CT 500mg OD
-Tab BIO D3 OD
-Tab Pantop 40mg OD
Hemodialysis taken on 8/3/22, 9/3/22, 15/3/22, 22/3/22
Monitoring vitals 4th hrly
-Tab MET-XL 50mg 
-Inj erythropoietin 4000U SC
-blood transfusion 1PRBC on 9/3/22

23/3/22
Fluid restriction less than 1.5 L/day
-salt restriction less 2gm/day
-Tab. NODOSIS 500mg po/BD
-Tab lasix 40mg BD
-Tab orofer BD
-Tab shelcal CT 500mg OD
-Tab BIO D3 OD
-Tab Pantop 40mg OD
Monitoring vitals 4th hrly
-Tab MET-XL 50mg 
-Inj erythropoietin 4000U SC
-tab Nicardia 20 mg tid
-Inj buscopan
-syp sucral

24/3/22
Fluid restriction less than 1.5 L/day
-salt restriction less 2gm/day
-Tab. NODOSIS 500mg po/BD
-Tab lasix 40mg BD
-Tab orofer BD
-Tab shelcal CT 500mg OD
-Tab BIO D3 OD
-Tab Pantop 40mg OD
Monitoring vitals 4th hrly
-Tab MET-XL 50mg 
-Inj erythropoietin 4000U SC
-tab Nicardia 20 mg tid
-Inj buscopan
-syp sucral





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