A case of 36 yrs old male with CKD came for regular dialysis

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve 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 and come up with diagnosis and treatment plan.

Leela Vamsi Roll no 23

A 36 yrs old male patient presented to the opd 1 yr back with complaints of pedal edema, facial swelling and sob . Now came for maintenance dialysis.

History of present illness.

A 36 yrs old male patient resident of ammanbrolu farmer by occupation.He was born out of non consanguineous marriage .He was apparently asymptomatic 2 yrs back. Now came for maintenance dialysis and he has sob,pedal edema and facial swelling . 

Past history 

He had similar complaints 2 yrs back  

he went to a hospital in nalgonda and has taken treatment for 2- 3 months then the symptoms relived .

After 1 yr he again developed similar symptoms and had 4-5 dialysis in a hospital in hyderabad .

Medical history : 

Known case of hypertension since 2 yrs 

No history of diabetes , tb , epilepsy , asthma . 

Family history 

No relavent family history 

Personal history 

Diet : Mixed 

Appetite : Low

Sleep : adequate 

Bowel and bladder movements : normal 

Alcohol consumption: occasional 

Smoking : No 

General examination 

Patient was c/c/c 

Pallor  : yes

Icterus   : No

Cyanosis  : No

Clubbing  : No

Lymphadenopathy   : No

Vitals 

Temperature  : 98.9

Pulse rate   :87

Respiratory rate : 24

Bp  : 160/70

Systemic examination 

Cvs :S1,S2 heard , no murmurs  

Respiratory system :

Dysnoea present

Vesicular breath sounds

Position of trachea - central  

Abdomen : scaphoid , no tenderness , no palpable mass , no free fluid , no bruits .

CNS : patient is conscious with higher functions intact . 

Provisional diagnosis : CKD on MHD 

Investigations : 

 

Treatment : Dialysis and Supportive .