Case Study 8

 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 patients 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 comment box is welcome.

December 09 , 2021


A 40 year old male patient came to OPD for dialysis 


HISTORY OF PRESENT ILLNESS 


 Patient was apparently asymptomatic 6 months

 back then he noticed decrease in urine output ,

 facial puffiness , pedal edema , swelling of arms

 and legs , nausea , vomiting , constipation ,

 abdominal discomfort then he went to a hospital in

 khammam , where investigations were done then

 he advised for advised for admission but he denied

 and joined kims where he presented with fluid

 overload and uremic symptoms then he started

 MHD through right femoral access . 


 He also has ulcer on the left foot , he got that

 during  farming where a stone pressed against the

 foot and a toe got amputated and then he took

 Ayurvedic medication after that he lost another

 toe . The foot was diagnosed to be diabetic foot . 


PAST HISTORY 


K/C/O DM since 16 years and he's on insulin

medication 

K/C/O Hypertension since 6 months and he's on

medication 

No K/C/O TB 


PERSONAL HISTORY 


Appetite - Normal 

Diet - Mixed 

Sleep - Inadequate 

Bowel and bladder movements - Regular 

Allergies - No known allergies 

Habits - occasional alcoholic 


FAMILY HISTORY 


No significant family history 


ON GENERAL EXAMINATION 


Patient is conscious , coherent and cooperative 

No pallor , icterus and cyanosis 

No lymphadenopathy 

No pedal edema 

Temperature - 98.4 

Pulse rate - 81 bpm

Blood pressure - 140/90 mmhg 

Respiratory Rate - 21 cpm 

SpO2 - 97 %


SYSTEMIC EXAMINATION 


CVS:


S1 S2 heard 

No murmurs 

No thrills 


RESPIRATORY SYSTEM:


BAE +

NVBS +


PER ABDOMEN 


Soft 

Non tender 


CNS: 


NFND


DIAGNOSIS 


CKD on MHD 



























INVESTIGATIONS 








































TREATMENT 

1. Fluid Restriction less than 1.5 L / day 

2. Salt Restriction less than 2.4 gm / day

3. Tab Lasix 40 mg/po/bd

4. Tab shelchal CT po/bd

5. Tab orofer  XT po/bd

6. Tab Cap bio - D3 po/bd

7. Inj. Erythropoitin 4000 IU s/c weekly twice 



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