50year male with CKD

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 is welcome."

Chief compliants : 

1) Pedel edema since 45 days 

2) Shortness of breath since 5 days 

3) Decreased appetite since 45 days 

History of present illness: 

50 year old male, father of 3 children , stone cutter by occupation.His routine is to get up in the morning and used to go the work by 9am and come back to home by 6pm.He likes spicy nonveg foods ,used to eat atleast 4times a week.

3 years back , patient stopped his occupation and started panipuri shop as his friends started doing the same business.

1 year back patient developed Low back ache along with Generalized weakness and vomtings and loss of appetite ,for which he went to the hospital and his renal parameters were deranged and started on conservative management.and also found to have hypertension.

Patient had regular follow up to hospital since then.

45 days back, patient developed pedal edema which was gradual onset , slowly progressive associated with decreased appetite and vomtings which was bilious ,non projectile and not resolved with medication and visted the hospital,suggested hemodialysis and patient attenders rejected and continued the same conservative management.

Since 5 days patient developed Shortness of breath which was gradually progressive and present even at rest.and visited Kim's and started on hemodialysis since 28/12/2022.

Past history:

Known case of Hypertension since 1 year

Known case of CKD since 1 year.

PERSONAL HISTORY

Diet - Mixed 

Appetite - Decreased

Sleep - Inadequate 

Bladder - Decreased urine output 

Bowel movements - Regular 

Smoker and alcohol stopped 10 years back

FAMILY HISTORY

• Not significant 

GENERAL EXAMINATION

Patient is concious , coherent , co-operative 

Well oriented to Time place person 

Thin build and moderately nourished 

• Pallor - absent 

• Icterus - Absent 

• Clubbing - Absent 

• Koilonychia - Absent 

• Lymphedenopathy - Absent 

• Pedal oedema - absent 

• JVP - Normal 

VITALS

• Temperature - 99°F 

• Pulse rate - 102bpm

• Respiratory rate - 20 cpm

• BP - 180/100 mmHg

• SPO2 - 98% on room air 

• GRBS - 142 mg/dl 

Provisional diagnosis: 

Chronic kidney disease 

known case of Hypertension 

Hemodialysis initiated on 28/12/22.