A 60Yr OLD 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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 year old male patient came to the opd with the chief complaints of
itching,weakness,loss of appetite since 5 days.
History of presenting illness-
Patient was apparently asymptomatic 6yrs back then he developed
Generalized itching
loss of appetite
on and off vomitings which is non bilious and contain food particles
fever on and off since 3 months.
6 years back
He had complaints of
severe pain and restriction of movements in joints
(started with the great toe and then the pip and dip joints and later progressed to other joints)
where tests indicated increased levels of uric acid,serum creatinine levels.....for this patient was given treatments (medications?) for gout.
4 months back
Patient started having complaints of loss of appetite,vomitings ,pain abdomen,back ache and went to hospital .
On checking his serum creatinine levels is raised(6.2mg/dl) and had undergone his first dialysis at Khammam hospital.
After dialysis patient had fever due to central line infection for which he was treated with antibiotics.
He had his last dialysis episode at gandhi 10 days back.
History of intermittent fever with chills and rigor since 3 months.
No history of burning micturition,decreased micturition,loin to groin pain
PAST HISTORY-
He is a known case of hypertension since 7 years(currently on met xl 25 mg)
No history of diabetes,tuberculosis,asthma,cad
PERSONAL HISTORY-
Routine activity:
Patient wakes up in the morning at 6 :30 am haves his breakfast
goes to the shop(he is a shopkeeper)
stays at shop till 1am
then have lunch sleeps for 2-3 hrs and then goes back to work
stay there till 9 pm and takes dinner
goes to bed by 11pm.
Appetite- Decreased since 4 months
Diet -mixed
Bowel and bladder movements-micturition normal , constipation
Sleep -reduced since 4 months
Addictions-stopped 2 months back(previously occasional drinker used to take 180 ml)
Family history-
no similar complaints in family
General examination-
Patient was conscious,coherent,and cooperative and well oriented to time place and person.
Vitals:- on admission
Date: 1/12. 2/12. 3/12. 4/12. 5/12
Temp- 98.6. 98.6. 98.4. 98.4. 98.4
PR - 83bpm. 82bpm. 82bpm. 82bpm. 82
RR- 16 cpm. 16cpm. 16cpm. 16cpm. 16
BP- 140/90. 130/80. 110/70. 110/70. 110/70
Pallor-absent
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy - absent
Investigations on 2/12/22
Dialysis done on 4/12/22
Hemodialysis chart:
Inj heparin-20000cc.
VP -100
Blood flow-180
TMP-120
RO water flow-500
BP-60/50
PULSE: 116
TEMP:98.6
GRBS:161
Treatment- given since 1/12/22 to 5/12/22
1.Tab. lasix 40 mg po b.d
2.T MET-XL 25 mg po ,o.d
3.T NODOSIS 500 mgpo,b.d
4. T OROFER -XT po o.d
5 SHELCAL po, o.d
6 Inj erythropoietin 5000IU ,SC weekly once
7 inj Iron sucrose 100 mg +100ml/NS IV OD weekly once
Discussion:
.jpeg)
Comments
Post a Comment