70 yr old male came for regular dialysis

17 july, 

Hi, I am Y.N.INDU VAISHNAVI 5th semester medical student. This is an online e log of patient's de-identified health data shared after taking his/her/guardian's 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.This elog also reflects my patient centered online learning portfolio       

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

70 Year old male resident of Thuppalapalli unemployed who lives on pension fund

Came to our hospital
For Dialysis as a regular part of his Dialysis schedule
He also complaints of Generalized weakness since 2 days

HOPI

Patient was apparently asymptomatic 5 years back
Then he started developing pain on his back which insidious in onset gradually progressive ,continuous ,dragging type,non radiating with no aggravating and relieving factors
Patient then went to a hospital and was diagnosed with chronic kidney disease and medications were given accordingly
Pain Relieved on medication
2yr ago the medications were not helping him with his pain and he was suggested to get a regular Dialysis
Since then Patient was regular Dialysis once every 4 days


PAST HISTORY

He had a trauma to his right leg 3rd toe 30 years back and was amputated
Hypertension since 10 years
Fracture of his right hip joint 10 years back But denied to get any surgery
No diabetes, TB, Epilepsy, asthma, hypothyroidism

TREATMENT HISTORY

he is taking Nifedipine for hypertension

PERSONAL HISTORY

He Used to take mixed diet but since Dialysis he is only consuming vegetarian diet
5 yrs back he was consuming alcohol cigarettes but stopped since then
Decreased micturition due to decreased intake of water and has ocassional Burning micturition

FAMILY HISTORY

no significant family history

DAILY ROUTINE

Wake up at 7:00 AM
Fresh up and have some tea
Breakfast at 9:00AM
Sleep from 11:00AM to 2:00PM
Lunch at 2:00PM
Watch TV and rest
Dinner at around 9:00PM

GENERAL EXAMINATION

with proper consent of the patient in all full lit and well aerated room the general examination was done
Patient was conscious and coherent
Moderately built and moderately nourished
Pallor


No icterus cyanosis clubbing of fingers lymphadenopathy Pedal odema

MEDICATIONS 

Fluid restriction <2L/day
Salt restriction <2g/day
Tab Noddsis 500mg po/BD
Tab Lasix 20 mg po/BD
Tab shellcall 500mg po/OD
Tab orofer xt po/OD
Cap bio D3 PO weekly once
Inj erythropoietin 4000 iu sc twice weekly
Tab nicardia 20 mg po/BD
Tab arkamine 0.1mg po/BD

INVESTIGATIONS






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