60 YEARS OLD MALE WITH CKD ON MHD

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.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 60 years male residing in nalgonda farmer by occupation prensented to OPD with a chief complaint of bipedal edema. 

HISTORY OF PRESENT ILLNESS
 Patient was asymptomatic 9 months back and developed edema in legs and it was subsided because of medication prescribed by local doctor

Later he again visited  local doctor complaining about edema in legs. On investigations of urine examinations doctor reported kidney failure and prescribed to have dialysis.

Since 9 months he undergoing sessions of dialysis in our hospital

Patient complaints coughing of blood after dialysis sessions
 
 PAST HISTORY
HYPERTENSION SINCE 1 year
No history of diabetes 

FAMILY HISTORY
No significant family history

GENERAL EXAMINATION
 Patient is conscious coherent cooperative
No pallor seen 
No cynosis
No icterus
No clubbing
Edema is seen

VITALS
Temp - 98.4
Bp - 130/70
Pulse - 84 beats/min
Respiratory rate - 12cpm/ min
 
SYSTEMIC EXAMINATION
CVS S1 AND S2 sounds heard 
CNS conscious, speech normal

PER ABDOMEN 
No fluid present 
No palpable mass
Liver not palpable
Spleen not palpable

INVESTIGATIONS:











PROVISIONAL DIAGNOSIS:

Chronic kidney disease 
Patient has been advised for hemodialysis twice a week


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