Case of 75 year old male patient with CKD
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 a series of inputs from an 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 centered online learning portfolio and your valuable inputs in the comment box is welcome.
Neha Tipparaju
9th Semester, Roll no. 100
CASE OF 75 YEAR OLD MALE PATIENT WITH CKD
Patient is a 75 year old , farmer by occupation and a resident of Suryapet.
He came with Chief complaints of:
Swelling of legs since 6 months
Lower back ache since 4 months
Scrotal swelling since 2 months
He was diagnosed as having Renal dysfunction about a year ago in another hospital. (Details not clear)
History of presenting illness:
Patient was apparently assymptomatic a year ago. Then he went for a routine check up to a hospital, he was diagnosed to have Renal failure.
He was asked to abstain from alcohol and smoking. He did not follow this, neither did he take any medication.
For 6 months, he was having swelling of feet, which was pitting type and relived on medication
He is also having Lower back ache since 4 months. Pain was sudden in onset but intermittent. It was on the right lower back, dragging type of pain radiating to buttock. It was also associated with numbness in legs and arms.
A scrotal swelling has also been present since 2 months which reduces on lying down and increases on working.
On 25/10, He recieved his 2nd COVID 19 vaccination after which he developed a mild fever, headache and easy fatigability. No burning micturition, diarrhoea, nausea or vomiting.
He is also complaining of decreased urine output. He does not get the feeling that bladder is empty after micturition.
Past history: No similar complaints in the past.
He is a known case of hypertension since 6 years, on regular medication.
Personal history: Smoking chutka since >40 years. 1 pack/day.
Drinks 90ml alcohol everyday since >40 years.
General Examination:
Patient is conscious, coherent and cooperative
Thinly built and nourished
Pallor was noticed
No icterus
No cyanosis
No clubbing
No generalized lymphadenopathy
No generalized edema
Multiple swellings are noticed over right and left arms and abdomen. They are non tender, soft in consistency, fluctuant, and mobile in all directions
Patient claims that they have been present since childhood and also present in his family
Systemic examination:
CVS: S1, S2 heart sounds heard, no murmer
Respiratory system: Bilateral air entry present
CNS: Intact
Abdomen: Soft and non tender, Bowel sounds heard no organomegaly
Investigations:
USG done on 30/10 in another hospital:
Provisional diagnosis: Chronic kidney disease causing Renal Osteodystrophy
Patient was advised Maintainance Hemodialysis 3 times a week
Post dialysis state:
He got 1st round of dialysis on 15/10
The process took 4 hours.
Afterwards, the patient did not complain of any giddiness, weakness, lightheadedness, fever or pain
BP measured was found to be 125/80.
He is scheduled for next round of dialysis in 2 days.
Comments
Post a Comment