Medicine case discussion
This is an online e log book to discuss our patient identified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient problems through a series of inputs from available global online community of experts with a aim to solve those patients clinical problem with collective current best evidence based inputs.
This blog also reflects my patient centered online learning portfolio and valuable inputs on the comments box is welcome.
I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation.
A 75 year old man had come to the OPD with chief complaints of pedal edema , low urine output and shortness of breath since the past 3 days.
The patient used to work as an farmer and his daily routine consisted of him waking up at 7am and he going to farm , his average work day ended at 4pm.
4 years back the patient presented with shortness of breath at local hospital for which he was diagnosed with CKD .
He was referred to KIMS for dialysis and had been getting dialysis done since the past 4 years.
4 months back patient again presented to KIMS OPD with fever and difficulty in swallowing liquids for which he was diagnosed with acute kidney injury secondary to CKD and was started with SHELCAL AND NOCORDIA.
He developed shoulder pain 15 days ago which was dragging type and was relieved upon rest.
History of present illness
Pedal edema since 3 days uptil leg and it subsided on rest.
Decreased urine output since 1 day
Sob on exertion and subsided on rest.
He developed right shoulder pain 15 days back which was insidious in onset and progressive in nature with restriction of movements ago which was dragging type and relieved upon rest .It was not associated with trauma or fall.
On 13th october the patient was referred to the orthopedic department for his shoulder pain wherein he was diagnosed with right shoulder osteoarthritis.
No neurological deficits present.
History of past illness:
1)a known case of acute kidney injury since 19/6/21.
2)a known case of hypertension since 4 years
3)a known case of Chronic kidney disease since 4 years on conservative management.
n/k/c/o DM,thyroid.
DRUG HISTORY :
1)H/O of NSAID use 7 years back repeatedly.
2)Patient underwent 4 sessions of hemodialysis.
3)Patient is taking medications for osteoarthritis from 13/10/21.
Personal history:
Diet :mixed
Appetite : decreased
bowels : regular
micturition :decreased urine output
no known allergies and no addictions
Family history:
No significant family history.
General Examination
patient was conscious , coherent and co-operative and examined in a well lit room
VITALS
pulse rate : 86bpm
respiratory rate : 18/min
BP: 110/70 mmHg
Temperature : Afebrile
GRBS : 127mg%
SpO2: 98% at room temperature
physical examination
Pallor : not present
icterus : not present
cyanosis : not present
clubbing : not present
lymphadenopathy : not present
Systemic examination
CVS
S1 and S2 are heard
no thrills and no murmurs
Respiratory
Dyspnoea is present
Vesicular breath sounds heard
Trachea is in central position
No wheezing
Abdomen
Scaphoid shaped abdomen
No tenderness
No palpable mass
No hernial orifices
No free fluid
liver and spleen are not palpable
bowel sounds are heard
CNS
Conscious and normal speech
normal gait
crainal nerves are normal
sensory system is normal
motor system is normal
Reflexes are normal
INVESTIGATIONS:
COMPLETE BLOOD PICTURE:
29/9/2021
3/10/2021
RENAL FUNCTION TEST:
29/9/2021
SERUM CREATININE:
31/8/2021
SERUM UREA:
31/8/2021
SERUM ELECTROLYTES:
31/8/2021
SERUM IRON:
31/8/2021
ANTI HCV ANTIBODIES -RAPID
HBsAG-RAPID
HIV RAPID TEST
ULTRASOUND
2D ECHO
ECG
DIAGNOSIS:
1)CHRONIC KIDNEY DISEASE ON MHD
TREATMENT :
1)FLUID RESTRICTION LESS THAN 1 LITRE/DAY.
2)SALT RESTRICTION LESS THAN 2grams/day.
3)NICARDIA 10mg BD
4)NODOSIS 500 mg PO/OD
5)T.SHEDCAL 500 mg PO/OD
6)T.LASIX 40 mg PO/BD
7)T.OROFER PO/BD
8)BP/PR/TEMPERATURE/SPO2 MONITORING.
HEMODIALYSIS :
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