70 Year old male with CKD on MHD


RACHANA GANGULA 
INTERN 




 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed 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 patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. 




 70 year old man resident of Narketpally and farmer by occupation came to the hospital with chief complaints of fever, pain abdomen, burning micturition since 20 days , decreased appetite, nausea , shortness of breath since 10 days. 


HOPI-


Patient was apparently asymptomatic 4 years back when he was admitted in a hospital because of fever and pain abdomen along with breathlessness and was then diagnosed with Chronic Kidney Disease and was started on maintenance hemodialysis since then for the next two years after which they discontinued the MHD due to personal reasons. 

He developed fever 20 days back not associated with chills, Intermittent,relieved on medication. He had complained of nausea and vomiting , non-bilious and non-projectile, containing food particles. It was associated with pain abdomen which was burning type and diffuse. 


PAST HISTORY 


Patient had a history of CerebroVascular Accident 25 years back.

He is a known case of diabetes Mellitus since past 4 years and is using regular medication (T. Metformin 500mg) 

He is not a known case of HTB, TB, Asthma, Epilepsy. 


FAMILY HISTORY 


No significant family history 

No history of CKD, DM,HTN,CVA, TB, Asthma or CAD among his immediate family members.


PERSONAL HISTORY


Diet: Mixed 

Appetite: decreased recently 

Sleep:Adequate 

Bowel and bladder: decreased urine output 

No known drug allergies

No addictions


GENERAL EXAMINATION 

Patient is conscious, coherant and cooperative, well oriented to time, place and person. 

pallor- conjunctival pallor present 

icterus, cyanosis, clubbing, lymphadenopathy- absent 

Pedal edema- 


Vitals at the time of admission: 

Temp-98.5

PR-92bpm

RR-26cpm

BP-130/70 mmHg

Spo2-93@ RA 


SYSTEMIC EXAMINATION 


CVS- S1S2 heard 

RS- dyspnea present

P/A- soft,non tender 

CNS- NAD 


PROVISIONAL DIAGNOSIS 


CKD on MHD 





7/4/34Investigations 








12/4/23

 






13/4/2023


ECG




2D ECHO- 

Mild TR+ Trivial AR+/MR+ 

NO RWMA. NO AS/MS Sclerotic AV

 Good LV systolic functions

Diastolic dysfunction+ NO PAH / PE


ULTRASOUND REPORT:


BILATERAL RENAL CORTICAL CYSTS

RIGHT GRADE 2 RPD CHANGES

LEFT GRADE 3 RPD CHANGES 

BILATERAL MEDULLARY CALCIFICATION IN KIDNEYS

IRREGULAR CIRCUMFERENTIAL URINARY BLADDER WALL THICKENING WITH THICK INTERNAL ECHOES S/o CYSTITIS

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