50 yr old male k/c/o CKD on hemodialysis since 5 months
This is an online e logbook to discuss our patients deidentified health data shared after taking her/guardian's signed informed consent
Here we discuss our individual patient 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 centre’s online learning portfolio and valuable inputs on the comment box is welcome.
CASE :
A 50yr old male resident of came with complaints of Shortness of breath, decreased urine output, pedal edema since 4 months
He was apparently asymptomatic 4 year back then developed generalized edema which is insidious in onset and gradual in progression associated with shortness of breath and went to outside hospital where is diagnosed with kidney disease from then he was on medication
5months back patient had pedal edema, shortness of breath and decreased urine output, burning for which he went to outside hospital and was advised to undergo dialysis, there he underwent dialysis for 4 times alternate days then came to our hospital after 1 month for further dialysis
From then on patient was on regular dialysis
Weekly twice
Now the patient is complaining of neck pain for which ortho referral was taken, they advised him to undergo physiotherapy
Patient is a k/c/o hypertension since 4 years for which he is on regular medication
No H/o diabetes, asthma, epilepsy, tuberculosis
He had a h/o usage of pain killers since 7 years for leg pain due to fracture of the leg
He has decreased appetite, bowel habits are regular
ON EXAMINATION
Patient is conscious, coherent, cooperative
He has Pallor and pedal edema
No icterus, cyanosis, clubbing, lymphadenopathy
VITALS:
Temperature- afebrile
BP - 140/90 mmHg
PR - 100 bpm
RR - 22 cpm
GRBS - 144 mg/ dl
SYSTEMIC EXAMINATION
CVS- S1, S2 heard
RS - Bilateral air entry present, normal vesicular breath sounds
Per Abdomen - soft, non tender
CNS - No focal neurological deficits
PROVISIONAL DIAGNOSIS:
CRF secondary to analgesic nephropathy and HTN with anaemia on maintaince haemodialysis since 5 months
Investigations :
CBP
Hb - 6.6
TLC - 20700
Neutro - 80
Lympho - 10
Eosino - 2
Mono - 8
Baso - 0
Platelet - 1.74
CUE
Albumin - +++
Sugar- nil
Pus cells - 2-4
RBC - nil
Serology - ( HIV, HCV, HbsAg ) - negative
RFT
Sr. Urea - 172
Sr. Creatinine - 7.6
Sr. Na - 134
Sr. K - 4.2
Sr. Cl - 97
USG
ECG
X ray C spine showing early spondylitis changes
Treatment :
- Fluid restriction ( < 1L) and salt restriction (<2g)
- TAB. NICARDIA 20mg PO TID
- TAB. PANTOP 40mg PO OD
- TAB. LASIX 40mg PO OD
- TAB. OROFER- XT PO OD
- TAB. SHELCAL 500mg PO OD
- TAB. ULTRACET 1/2 QID
- Physiotherapy for neck
- As patient Hb was 6.6 g/dl, he was tranfused with PRBC
