CKD On MHD
A 56 Year old female with chronic kidney disease on maintainance on hemodialysis
This is 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .
K.shirisha
Rollno;60,
9th semester.
I’ve 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.
Case discussion ;
A 56 year old female came to opd with chief complaints of fever,shortness of breath ,cough since 1 week.
History of present illness;
The patient was apparently asymptomatic 6 years ago then she developed fever, vomitings, abdominal pain she visited local hospital there she diagnosed as renal calculi and hypertension .she was taking nicardia 20mg.for renal calculi conservative treatment has taken.and again 3 years back she had sob,fever, vomitings she visited Hyderabad hospital there she dignosed as chronic renal failure .she was treated conservatively.
On February 1 2021 she again developed sob -grade-3,fever, vomitings, she visited to our hospiatal and initiated on dialysis.
From February she is on maintainance on hemodialysis weekly twice.
On october13 she came to opd with complaints of fever high-grade, sudden in onset, with evening rise of temperature, intermittent in nature,not associated with chills and rigor
Shortness of breath grade-3,
Cough which was productive , with copious amounts of expectorant.associated with postural variation which was increased during sleep
C/o nausea
C/O facial puffines
No H/O reduced urine output, burning micturition,pedal edema, palpitations
Past history ;
She is aK/c/o hypertension since 6years,
Treatment ; nicardia20mg
Not a K/c/o of diabetes,tb,asthma, epilepsy, thyroid and heart diseases
Family history ; insignificant
Personal history;
Diet ; vegetarian
Appetite; decreased
Boweland bladder movements ; regular
Sleep; adequate
No addictions
General examination;
The patient is conscious, coherent, cooperative and we'll oriented to time ,place, person
Moderately built and we'll nourished
pallor - present, no icterus, cyanosis, clubbing,edemea,lymphadenopathy
Vitals;
Temperature; febrile
Blood pressure; 140/90mmhg
Heart rate; 80bpm
Respiratory rate; 24 cpm
Sp02 ; 98%
Systemic examination;
Respiratory system: Bilateral air entry present,normal vesicular breath sounds,
Trachea is central
CVS ; S1,S2 heart sounds heared ,no murmurs
Per abdomen; soft,non tender,no engorged viens are seen ,no organomegaly
CNS; no focal neurologic deficit
Investigations;
Investigations
On13/10/2021
RFT;
SERUM IRON
HEMOGRAM
BLOOD GROUPING
CUE;
RANDOM BLOOD SUGAR;
ULTRASOUND;
B/L Grade-3 RPD
*B/L mild pleural effusion
2D-ECHO
ECG;
On16/10/2021
Hemogram
RFT
On 16/10/21;
Urea ; elevated
Creatinine; elevated
Chest Xray
PROVISIONAL DIAGNOSIS; CHRONIC KIDNEY DISEASE ON MHD, ASSOCIATED WITH COMMUNITY ACQUIRED PNEUMONIA.
TREATMENT;
On14/10/21
✓fluid restriction <1.5lt/day
✓salt restriction<2g/day
✓inj.Augmentin 1.2gm i.v
8am-8pm-bd
✓inj.pantop40mg-po-od
✓tab nicardia 20mg-po
✓tab.lasix40mg-po-od
✓tab shelcal500mg-po-od
✓tab livogen-po-od
✓tab Bio D3 0.25 mg.po.od
On 14/10/21;
fluid restriction <1.5lt/day
✓salt restriction<2g/day
✓inj.Augmentin 1.2gm i.v
8am-8pm-bd
✓inj.pantop40mg-po-od
✓tab nicardia 20mg-po-tid
✓tab.lasix40mg-po-od
✓tab shelcal500mg-po-od
✓tab livogen-po-od
✓tab Bio D3 0.25 mg.po.od
On 15/10/21
fluid restriction <1.5lt/day
✓salt restriction<2g/day
✓inj.Augmentin 1.2gm i.v
8am-8pm-bd
✓inj.pantop40mg-po-od
✓tab nicardia 20mg-po-tid
✓tab.lasix40mg-po-od
✓tab shelcal500mg-po-od
✓tab livogen-po-od
✓tab Bio D3 0.25 mg.po.od
On16/10/21;
fluid restriction <1.5lt/day
✓salt restriction<2g/day
✓inj.Augmentin 1.2gm i.v
8am-8pm-bd
✓inj.pantop40mg-po-od
✓tab nicardia 20mg-po-tid
✓tab.lasix40mg-po-od
✓tab shelcal500mg-po-od
✓tab livogen-po-od
✓tab Bio D3 0.25 mg.po.od
On17/10/21
fluid restriction <1.5lt/day
✓salt restriction<2g/day
✓inj.Augmentin 1.2gm i.v
8am-8pm-bd
✓inj.pantop40mg-po-od
✓tab nicardia 20mg-po-tid
✓tab.lasix40mg-po-od
✓tab shelcal500mg-po-od
✓tab livogen-po-od
✓tab Bio D3 0.25 mg.po.od
18-10-21 ;
fluid restriction <1.5lt/day
✓salt restriction<2g/day
✓inj.Augmentin 1.2gm i.v
8am-8pm-bd
✓inj.pantop40mg-po-od
✓tab nicardia 20mg-po-tid
✓tab.lasix40mg-po-od
✓tab shelcal500mg-po-od
✓tab livogen-po-od
✓tab Bio D3 0.25 mg.po.od
° Hemodialysis is done today
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