Thursday, October 28, 2021

CASE OF CHRONIC KIDNEY DISEASE

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. 

CASE:-
A 40yr old male came with chief complaints of 
•Pedal edema
•Decrease in urine output
•Facial puffiness

HISTORY OF PRESENTING ILLNESS:-

•Fever with increase in temperature and slight chills especially at night.
•Lower back pain
•I could observe slight hump at back of neck with pain.
•Cough with phlegm

HISTORY OF PAST ILLNESS:-

Not a known case of diabetes mellitus, hypertension,asthama.

TREATMENT HISTORY:-
No relavent history

PERSONAL HISTORY:-

 He is married and a farmer by proffesion.
Diet-nonveg
Bowel movements-regular
Micturition-decreased in output.no burning sensation
He is a non alcoholic and doesn't smoke.

#Normal daily routine of 40yr old male is he wakes up at 5:00a.m and finish his daily activities and have idly at 6:30a.m and eats his breakfast at 10:00a.m(rice and curry) goes out does farming in feilds and then comes back home at 6:00p.m and take his dinner(rice and curry).He occasionally goes to market for vegitables and things and chit chat with freinds and neighbors.He sleeps by 8-9:00pm.

FAMILY HISTORY:-
No relavent family history.

GENERAL EXAMINATION:-
Patient was consious, coherent and cooperative.

VITALS:-
Temperature-98.4F
Pulse rate-84/mm
Respiratory rate-24/mm
Blood pressure-130/70mmHg
Spo2-98% at room air
GRBS-136mg/do

Pallor-present
Ictrus-present
Clubbing-absent
Cyanosis-absent
Oedema-pesent in feet(pitting type)
Lymphadenopathy-absent



SYSTEMIC EXAMINATION:-

ABDOMEN:-
Scaphoid shaped abdomen
No tenderness
No palpable mass
No organomegaly
Bowel movements are heard-sluggish
Liver and spleen not palpable.

CVS:-
S1 and S2 heard
No thrills
No murmurs

RESPIRATORY SYSTEM:-
Dyspnoea absent
Wheeze absent
Position if trachea is center
Breath sounds central

INVESTIGATIONS:-

COMPLETE BLOOD PICTURE:-

Hepatitis B

Hepatitis C

Serum electrolytes:-
Serum creatinine:-


Blood urea:-

Haemogram:-
ULTRA SOUND OF ABDOMEN:-
PROVISIONAL DIAGNOSIS:
Chronic kidney disease on haemodialysis.


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