Sahil ,Roll no :143


July 28, 2022

CKD

This is 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 patients clinical problems with collective current best evidence based inputs 


Chief complaints :

   A 60 yr old male Pt came with cheif compliants of :

* History of decreased urine output since 2 months.

* shortness of breath since 2 months

* Bilateral pedal edema.


History of present illness:


* patient was apparently asymptomatic 2months back.

* Then he developed decreased urine output and shortness of breath which is gradually progressive from grade 1 to grade 3 

* History of pedal edema ,bilateral and progressive gradually ,pitting type with facial puffiness, aggrevated by walking and relieved by sitting 

History of past illness:

* Hypertension- using medication since 4 years.

*CKD on MHD - 1month ago.10 times hemodialysis is done.

* Diabetic since 2 yrs 

*Blood transfusion done 

Personal history:

*Martial status: married

*loss of appetite

*vegetarian

*Bowel: regular

*Decreased urine output 

*No allergies

* No addictions


Family history:


* No history of diabetes , hypertension, Heartdiesases ,Cancers, Tb ,asthma.

General Examination:

* patient is pallor

*No cyanosis 

*No lymphadenopathy

Pedal edema present 



Vitals:

Temperature: 98.6 F

Pulse rate: 92/ minute

Respiratory rate: 18/minute

Blood pressure: 130/80 mg

SpO2 : 98%

Systemic Examination :

Cvs..

*No thrills

*No murmurs

*S1 and S2 are present


Respiratory system

* No wheezing

* Dysnopea 

*position of trachea - central

*vesicular breath sounds

Abdomen

*schapoid abdomen 

*Tenderness is present

*No palpable mass

*No free fluid 

* Liver and spleen not palpable

CNS.

NAD 

Reflexes

All reflexes are present. 




Diagnosis

Chronic kidney disease on maintaince of hemodialysis(MHD).

Investigations ordered:

*Ecg

*CBP

* Blood grouping and typing

*RFT

*serum Iron

*USG abdomen


*












Treatment  

SALT( < 2 g/day) AND FLUID RESTRICTION (<1L/day) 

Strict DIABETIC DIET 

TAB.LASIX 40mg /PO/BD 

TAB.NICARDIA 20mg /PO/BD 

TAB .NODOSIS 500mg /PO/BD

TAB SHELCAL 500mg /PO/OD 

TAB.OROLEX XT /PO/BD

BP,PR,SPO2 charting 4 th hrly 

I/O CHARTING 

GRBS CHARTING 

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