GENERAL MEDICINE (CKD)

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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. collective current best evidence based inputs. 

A 65 year old male who is daily labor by occupation came to the OPD for MHD for CKD

HISTORY OF PRESENT ILLNESS:

Normal routine of the patient:

He used to get up at 6 in the morning, used , then breakfast at 8 (rice)  hot then , he used to have lunch at 2 which is rice(cold) again.  and have dinner at 8 PM(rice)hot  and sleep after that.

The Patient was apparently asymptomatic 4months back then he had developed fever first which didn't subside even after 4 days. He then experienced shortness of breath while still having fever. 

He went to a local doctor, symptoms did not subside and then came to our OPD where he was diagnosed with CKD and hypertension 

Since the patient joined the hospital, he is undergoing dialysis twice per week and sometimes he used to have only shortness of breath while walking after initiation of treatment. No complaint of fever, and having edema 

 

HISTORY OF PAST ILLNESS:

The patient is not a known case of diabetes, epilepsy,tuberculosis,asthma

The patient has undergone accident so he is having backpain since 15 year and he is on medication since 15 yrs 

PERSONAL HISTORY

- the patient has  loss of appetite

- bladder movements are normal

-no sleep disturbances 

FAMILY HISTORY:

There are no similar complaints in the family members

TREATMENT HISTORY:

The patient is not a known case of drug allergy

GENERAL EXAMINATION:

-Patient is conscious,coherent and cooperative at the time of joining 

-No pallor 

-No icterus

-No lymphadenopathy 

-No cyanosis 

-No clubbing of fingers

- edema of feet

VITALS - temperature:98.4F

-pulse rate:88bpm

-respiration rate:19/min

-bp:140/90

-spo2-99

Grbs:122mg

SYSTEMIC EXAMINATION:

CVS

-no thrills 

-no cardiac murmurs

S1&S2 sounds are heard

RESPIRATORY SYSTEM 

- Position of trachea is central 

- Bilateral air entry is normal

- Normal vesicular breath sounds heard

- No added sounds

ABDOMINAL EXAMINATION  

abdomen is not tender

- no palpable mass or free fluid

CNS

- Patient is conscious

- Speech is present

- Reflexes are normal

INVESTIGATIONS