General Medicine E-Log
A case of 36 yrs old male with CKD came for regular dialysis
October 25, 2021
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
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I have 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.
A 36 yrs old male patient presented to the opd 1 yr back with complaints of pedal edema, facial swelling and sob . Now came for maintenance dialysis.
History of present illness.
A 36 yrs old male patient resident of ammanbrolu farmer by occupation.He was born out of non consanguineous marriage .He was apparently asymptomatic 2 yrs back. Now came for maintenance dialysis and he has sob,pedal edema and facial swelling .
Past History ;
He had similar complaints 2 yrs back
he went to a hospital in nalgonda and has taken treatment for 2- 3 months then the symptoms relived .
After 1 yr he again developed similar symptoms and had 4-5 dialysis in a hospital in hyderabad .
Medical history :
Known case of hypertension since 2 yrs
No history of diabetes , tb , epilepsy , asthma .
Family history
No relavent family history
Personal history
Diet : Mixed
Appetite : Low
Sleep : adequate
Bowel and bladder movements : normal
Alcohol consumption: occasional
Smoking : No
General examination
Patient was c/c/c
Pallor : yes
Icterus : No
Cyanosis : No
Clubbing : No
Lymphadenopathy : No
Vitals
Temperature : 98.9
Pulse rate :87
Respiratory rate : 24
Bp : 160/70
Systemic Examination
Cvs :S1,S2 heard , no murmurs
Respiratory system :
Dysnoea present
Vesicular breath sounds
Position of trachea - central
Abdomen : scaphoid , no tenderness , no palpable mass , no free fluid , no bruits .
CNS : patient is conscious with higher functions intact .
Provisional diagnosis : CKD on MHD
Investigations :
