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