36 year old with CKD on MHD

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. 
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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:

Chief complaints-

1. Pedal edema since 3 months 
2. Shortness of breath since 1 week 
3. Fever with chills since since 3 days 

History of Presenting Illness-

Patient was apparently asymptomatic 3 months back, then he developed, 

1. Pedal Edema-

• Insidious in onset
• Gradual in progression 
• Since 3 months
• Bilateral, pitting type up to thigh
• Relieved on going regularly to his dialysis appointments
• Associated with the following- 

2. Shortness of Breath- 

• Sudden in onset, 
• Gradual in progression and intermittent since 1 week
• Mainly present and aggravated when not going to his dialysis on time, otherwise not present. 

3. Fever-

• Insidious in onset
• Gradual in progression 
• Since 3 days 
• Relieved on medication 
• Associated with chills and stomach pain that was sudden in onset, gradual in progression, in the upper part of the left side of the abdomen and took medication for it but wasn’t relieved, hence the reason for his hospital admission. 
• Not associated with cough, and cold. 

Past History-

Chronic Kidney Disease with Maintenance Hemo- Dialysis 

• History of hypertension since 4 years 
• No history of Diabetes, Asthma, Tuberculosis, and Epilepsy. 
• No history of similar complaints in the past.  

Treatment History-

• Nicardia for hypertension 
• Dollo for fever 

Personal History- 

• Lost appetite (patient lost 14 kgs in the last 6 months) 
• Mixed diet 
• Regular Bowel and Bladder movements 
• Adequate sleep 
• No such habits. 

Allergies History- 

No known allergies 

Family History- 

Insignificant

General Physical Examination- 

Vitals- 

1. Heart Rate- 108 bpm
2. Respiratory Rate- 22 cpm
3. Temperature- Afebrile 
4. Blood Pressure- 170/100 mmHg

No signs of Pallor, Icterus, Cyanosis, Clubbing, Oedema, Lymphadenopathy. 

Systemic Examination-

1. Cardiovascular System-

• S1S2 sounds heard
• No murmurs 

2. Respiratory system-

• Position of Trachea- Central 
• Breath sounds- Vesicular 
• No Dyspnoea or wheeze present. 

3. Abdomen-

• Shape of abdomen- Scaphoid
• Tenderness- not present 
• Palpable masses- Not present 
• Hernial orifices- normal 
• Free fluid- no
• Bruits- Absent 
• Liver and spleen- not palpable 
• Bowel sounds- present 

4. Central Nervous System-

• Patient is conscious, coherent and alert, with regular speech. 
• No signs of meningitis 
• Normal Cranial nerves functions, motor and sensory system appears intact. 

Provisional Diagnosis- 

Chronic Kidney Failure on Maintenance Hemodialysis 

Investigations- 

Ultrasound Report Impression- Bilateral Grade 3 Renal Pelvic Diameter with simple renal cortical cysts

Treatment- 

1. Fluid restriction less than 1.5 L/day
2. Salt restriction less than 2g/day
3. Tab LASIX 40mg PO/BD
4. Tab NICARDIA 20mg PO/BD
5. Tab NODOSIS 500mg PO/BD
6. Tab OROFER PO/BD
7. Tab SHELCAL 500mg PO/BD 
8. Inj ERYTHROPOIETIN S/C once weekly
9. Inj HAI S/C according to GRBS 
10. Tab EPTOIN 100mg PO/TID