A 62 year old male with CKD

 Welcome to my blog! I am Varshitha Kalidindi, a 4th year medical student. This is an e-log to discuss our patient's de-identified health data after taking informed consent of the patient. It also reflects patient centered online learning portfolio.

I will be looking forward to some feedback and valuable inputs through the comments box provided below. 

I have been given this case 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, diagnosis and treatment plan.

CASE:-

A 62 year old male, sari weaver by occupation, came to the hospital 2 days ago with complaints of pedal edema since 6 months, decreased urine output since 1 month, vomiting since 10 days and shortness of breath and facial puffiness since 2 days.

HISTORY OF PRESENTING ILLNESS:-

The patient was apparently alright till 6 months ago, when he started noticing pedal edema. He got his creatinine levels checked (3.2) and was diagnosed with CKD. He was asked to come back when his urine output decreases. He had been getting his creatinine checked regularly till 1 month ago, when he finally started experiencing a decreased urine output. He got his creatinine levels checked at the time (9.4).

He was then given diuretics, which he has been using regularly till 10 days and, when he started vomiting whatever food he was eating. For 6 days, he was vomiting out whatever he was eating, then he had watery vomit for 2 days and then spit-like vomit for 2 days. He is retching even now.

PAST HISTORY:-

15 years ago, patient had chikungunya. On routine examination he was found to be diabetic. He has been using medicines since then.

4 years ago, patient came to the hospital with complaints of cough for 4-5 days. All test results were negative for TB, but chest x-ray showed a suspicious cavity, for which the patient was started on tb regimen, which followed through for 6 months and finished the course. It was also discovered that he had hypertension on examination.

8 months ago, while he was lying down on a bench, he had a hypoglycemic episode which caused him to fall off the bench. He had a fracture in his left knee as a result.

6 months ago, the patient had pain in the knees and back, for which he got examined and on x-ray it was found that he had fluorine in his bones.

FAMILY HISTORY:-

TREATMENT HISTORY:-

PERSONAL HISTORY:-

Appetite: decreased

Diet: mixed, reduced meat intake and purine rich foods.

Sleep: adequate 

Bowel movements: decreased

Micturition: decreased 

Addictions: occasionally drinks alcohol, 1-2 pegs at a time. Drank last 5 years ago

GENERAL EXAMINATION:-

The patient is conscious, coherent, cooperative and well-oriented to time, place and person.

The patient is moderately built and well-nourished. Anasarca seen.

Bilateral pedal edema present 

Vitals:-

Temperature: 98°F

Blood pressure:150/70mmHg

Pulse rate:88bpm

Respiratory rate:22cpm

Spo2(at admission): 98%

GRBS(at admission):314 mg%

SYSTEMIC EXAMINATION:-

CNS: patient is conscious, coherent, cooperative, well-oriented to time, place and person.

CVS: S1,S2+, no murmurs

Respiratory system: dyspnea present, trachea central, no crepts heard.

Abdomen: abdomen is distended, umbilicus everted

Abdomen was soft and non-tender, no palpable organs

INVESTIGATIONS:-

On 9/7/2023

On 10/7/2023

PROVISIONAL DIAGNOSIS:-

TREATMENT:-