60yr old with ckd

 

60 Year Old with CKD

November 10, 2022

 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 Elog book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment .

 11 Nov 2022


A 60 YEAR OLD FEMALE Resident of Narketpally, farmer 20 years ago

Chief Complaint

Pedal edema since 2 months

Shortness of breath since 2 months

History of Presenting Illness

Patient was apparently asymmtomatic 20 years back then she went for routine check up where they diagnosed her with kidney problem. Since then she is on Sodium bicarbonate twice daily and Calcitriol once daily.

3 years back she had a episode of giddiness, she was diagnosed as Hypertension. Since then she is on Nicardipine twice daily.

8 months back she had pedal edema, anuria 1day, decreased appetite. They started her on dialysis 2 per week.

2months back she had bilateral pedal edema, insidious in onset, gradually progressive in nature relieved on dialysis. She has shortness of breath grade 4 aggravated on sleeping, relieved on dialysis. Decreased urine output.

Since 1 month she is bedridden.

Yesterday she came for dialysis, she was first given 1 unit of PRBC,  then dialysis was done,  after that she developed Shortness of breath grade 4


Past history

Known case of Hypertension

Not a known case of DM, Asthma, TB, Epilepsy, Thyroid.


Family History

Not significant


Personal History

Diet mixed

Appetite Decreased

Sleep Decreased

Bowel and bladder movements Decreased

No addictions and no known allergies


GENERAL EXAMINATION

Patient is conscious,coherent and cooperative, thin built and malnourished

Pallor 



No Icterus, Clubbing, cyanosis,lymhadenopathy, pedal edema

Vitals

 Temp: afebrile 

PR- 70/Min    

RR- 20/Min

BP- 130/90 mmHg


SYSTEMIC EXAMINATION

CVS- S1 S2 heard, Loud P2, no murmurs


RS- NVBS, Crepitus present Bilaterally.

Trachea central


P/A - Soft, non Tender, no organomegaly


CNS- NFND

Tone, power and reflexes are normal.






Investigations







Diagnosis

Chronic Kidney Disease on Maintenance Hemodialysis


11 Nov

S
Complaint of loose stools 3 episodes

O
Bp-120/60mmhg
Pr-78bpm
Rr-28cpm 
Temp- 98.5F
Spo2-100 with 10 lit o2

A

CKD on MHD










Discussion



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