60 YEAR OLD MALE WITH CKD

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SNEHA CHAUHAN 

ROLL NO- 126

2017 BATCH

9th SEMESTER 


  • This is an online E-log to discuss our patient’s de-identified health data shared after taking his/her/guardian’s 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. 
  • This E-log also reflects my patient centered online learning portfolio and your valuable inputs on comment box are welcome. 


I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis” to develop my competence in reading and comprehending clinical data including history, clinical findings and come up with diagnosis and treatment plan. 



Following is the view of my case-


CASE:


A 60 year old male came with chief complaints of-


  • Pedal edema since 1 week 
  • Shortness of breath since 1 week 
  • Decreased urine output since 1 week. 


Past History- 

  • History of Hypertension since 7 months 
  • No history of Diabetes, Asthma, Tuberculosis .


Family History- 

No significant family history 


Treatment History- 

No significant medical or surgical history 



Personal History- 

  • Appetite- normal 
  • Mixed diet
  • Regular Bowel and Bladder movements


Allergies history- 

No history of any allergies 


General Physical Examination- 

  1. VITALS- 
  • Pulse rate- 84 beats per minute 
  • Respiratory Rate- 24 cycles/minute
  • Blood pressure- 130/70 mmHg
  • Temperature- Afebrile
  • Oxygen Saturation- 98%
  • GRBS- 136 mg%
  1. Pallor- Present 
  2. Icterus- Absent
  3. Cyanosis- Absent
  4. Lymphadenopathy- Absent
  5. Edema of feet- Present 
  6. Clubbing of fingers/toes- Absent









Systemic Examination- 

  1. Cardiovascular System-
  1. Thrills- No
  2. Cardiac sounds- S1 S2 heard
  3. Cardiac murmurs- No


  1. Respiratory System-
  1. Wheeze- No
  2. Position of Trachea- Central 
  3. Breath sounds- Vesicular 


  1. Abdomen-
  1. Shape of Abdomen- Scaphoid 
  2. Tenderness- Not present 
  3. Palpable mass- No
  4. Hernial orifices- Normal
  5. Free fluid- Absent
  6. Bruits- No 
  7. Liver- Not palpable 
  8. Spleen- Not palpable
  9. Bowel Sounds- Heard
  10. Genitals- Normal


  1. Central Nervous System-
  1. Conscious, coherent and Cooperative 
  2. Normal Speech
  3. No signs of meningeal irritation 
  4. Cranial nerves, Motor system and sensory system findings are normal 



Provisional Diagnosis- 

Chronic Kidney Disease on Maintenance Haemodialysis 



Progress Record- 

  1. On Date of admission (25/10/2021)-

On examination-

  • Patient is Conscious, coherent and cooperative 
  • Blood pressure- 130/70 mmHg
  • Pulse Rate- 84 beats per minute
  • CVS- S1 S2 sounds heard
  • RS- Bilateral air entry present, no visible breath sounds. 
  • CNS- no such findings 
  • P/A- Soft 


Investigations- 











Treatment and Plan of care- 

Plan of care- Dialysis 


  • Salt Restriction < 2g/day
  • Fluid Restriction < 1.5 L/day
  • Tab NICARDIA 20 mg 
  • Tab NODOSIS
  • Tab SHECAL 500mg 
  • Tab OROFER 
  • Inj Erythropoietin 4000IU weekly once 

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