57 year old male patient with CKD on Maintenance Hemodialysis

 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. 

CASE DETAILS :

This is a case of a  57 year old male patient who hails from a rural area of nalgonda district..

He came to the OPD with the chief complaints of 

* BILATERAL PEDAL EDEMA since 2 months

HOPI ::

Patient was apparently asymptomatic 2 months back

Then he developed bilateral pedal edema which is of pitting type which was gradually progressive. 

He went to a hospital at Hyderabad and 

i/v/o high creatinine levels

4 sessions of Dialysis were done over 1 week

He came to KIMS, Narketpally on 22/12/2021 for further sessions of Dialysis

No history of decreased output, Shortness of breath

PAST HISTORY ::

There were no similar complaints in the past. 

Patient is a known case of hypertension since 2 months on medication ( NICARDIA 10mg)

No DM , asthma , Tuberculosis, CAD , epilepsy.

NO history of previous surgeries.

PERSONAL HISTORY ::

Mixed diet with normal appetite

Bowel and Bladder movements regular ,

Consumed alcohol for last 20 years stopped since 2 months

Smoking for last 20 years but stopped since past 2 months

No drug or food allergies.

GENERAL EXAMINATION ::

Patient is conscious, coherent and cooperative.

He is moderately built and nourished.

Pallor - Absent

Icterus - absent 

Clubbing - absent 

Cyanosis- absent 

Lymphadenopathy - absent 

Edema - PRESENT ( BILATERAL PEDAL EDEMA).

VITALS ::

Temp. : Afebrile.

Pulse rate : 84 bpm 

Respiratory rate : 20 per min.

B.P : 140/90 mm of Hg.

spO2 : 98% at room air.

SYSTEMIC EXAMINATION ::

Respiratory system:

Normal vesicular breath sounds heard.

CVS :

S1 , S2 heard , no murmurs.

CNS : 

No sensory and motor abnormalities.

Per abdomen :

Soft and non tender , no organomegaly.

INVESTIGATIONS

PROVISIONAL DIAGNOSIS :

CHRONIC KIDNEY DISEASE on MAINTENANCE HEMODIALYSIS 

TREATMENT ::

Fluid restriction ( less than 1.5litre per day)

Salt restriction ( less than 2gm per day )

Tab. Nicardia 20mg × po × B.D.

Tab. Lasix 40mg × po × B.D.

Tab. Orofer × B.D.

T Nodosis 500mg × po× B.D.

 T. SHELCAL