Chronic kidney disease on MHD 03 A.Sai Tarun

 GENERAL MEDICINE E-LOG 5-07-2021

Greetings to everyone who are reading my blog. This is A.Sai Tarun of 3rd semester. Rollno-03. Below is an E- Log describing patient centered approach and discuss our patient de-identified health data shared after taking her guardian's signed informed consent.


INTRODUCTION

A 60 year old male patient with Chronic Kidney Failure 

CHIEF COMPLAINTS 

 1) Decreased urine output since 2 months 

2) sob since 2 months 

3) b/l pedal edema since 1 -2 months 


HISTORY OF PRESENT ILLNESS

➜Patient was apparently asymptomatic for 4months. 

➜H/O Decreased urine output.

➜Facial puffiness is seen.

 ➜H/O Pedal oedema.

HISTORY OF PAST ILLNESS

➜Known for HTN and DM.

➜Has past history of blood transfusion.

➜Not a k/c/o of CAD, Asthma, TB.

➜CKD on MHD:-1 month- 10 hemodialysis done.

TREATMENT HISTORY

➜He has been on conservative drug treatment for Hypertension and DM.

PERSONAL HISTORY

Appetite normal 

Diet mixed 

Bowel and bladder : regular 

 Sleep adequate 

 Addictions : no addictions 


Family history : not significant 


 GENERAL EXAMINATION

⇒Patient is conscious coherent cooperative.

⇒Patient is moderately build and moderately nourished.

⇒no icterus. 

⇒pallor -present

⇒oedma-present

⇒no lymphadenopathy

VITALS

 ⇒Pulse Rate : 92 bpm 

 ⇒BP: 130/80 mm hg

⇒ spo2: 96% 

⇒Respiratory rate: 18/min

⇒Temp :98.6 F

CVS EXAMINATION

⇒ thrills - No

⇒s1 , s2 heard.  

⇒No murmurs 

CNS EXAMINATION

⇒Cranial nerves: intact 

⇒Motor : normal 

⇒Sensory : normal

RESPIRATORY

⇒Normal vesicular breath sounds heard 

⇒No crepts

⇒Dyspnoea - Yes

⇒ Position of trachea - central 

PER ABDOMEN

⇒Soft , non tender

CENTRAL NERVOUS SYSTEM

⇒Level of consciousness - conscious

⇒Speech - Normal

⇒No signs of meningeal irritation

⇒Cranial nerves - Normal

⇒No motor or sensory deficit


INVESTIGATIONS:-


COMPLETE BLOOD PICTURE





BLOOD GROUPING






SERUM IRON





ELECTROCARDIOGRAM



RENAL FUNCTION TESTS








ULTRASOUND









PROVISIONAL DIAGNOSIS

Chronic kidney disease on MHD


TREATMENT

1. salt resriction (<2g/day)

2. fluid restriction (<1lt/day)

3. strict diabetic diet

4. tab aciloc 40mg /po/BD

5. tab nicardia 20mg /po/BD

6. tab nodosis  500mg/po/BD

7. tab shelcal 500mg/po/OD

8. tab calex XT /po/BD

9. Bp/PR/spo2 monitoring











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