A 60 year old male came with CKD

 This is an online e-log book to discuss our patient de-identified health data shared after taking his / her / guardian's signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.

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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 coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.

CHIEF COMPLAINTS : 

A 60 year old male resident of kodad presented with chief complaints of 

Vomiting on and off and decreased appetite since 4months.

Fever with chills on and off since 3 months. 

Generalized itching  5 days back.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 6 years back and then he developed joint pains in the great toe and proximal inter-phalengeal joint and had migrating joint pains and  was diagnosed as gout in their regional hospital and was found that creatinine was increased, he used allopathy medication and ayurvedic medication for gout, he was on medication ( ?no records) for kidney problem for few years and stopped, 

4 months back he developed generalized itching all over the body, anorexia, epigastric pain, vomiting which is non billious with food particles in it and he went to regional hospital where he was diagnosed as CKD creatinine (6.2 mg/dl) and underwent 2 sessions of  dialysis and he developed infection after dialysis (central line induced) and he was admitted in icu for one day and treated,  

he also had  h/o of  low grade fever since one month with chills and rigors since one month which is continuous subsided  on using medication, h/o of constipation since many years, dry cough since 2 months, itching subsided after dialysis and recurrent itching episodes were present for which he used medication and it got subsided , 

since one week he is having diarrhea, anorexia, weakness and admitted in our hospital and he is on medication (?)of ckd since 6 days and 

No H/O  burning micturition and decreased micturition, pedal oedema and

day before yesterday he was admitted for dialysis and had dialysis yesterday night.

PAST HISTORY:

Patient is hypertensive since 7 years  and not on regular medication.

Not a known case of diabetes 

No h/o of seizures, tb, asthma, leprosy.

3 months back underwent dialysis at khammam private hospital.

H/o itching on neck region and chin area and took medication and got subsided 3 months back

PERSONAL HISTORY:

Diet-mixed 

Appetite- decreased 

Sleep-decreased

Bowel and bladder movements- has constipation 

 Addictons- occasionally drinks alcohol 180 ml.

Patient wakes up around 7am in the morning and gets fresh up and takes breakfast around 9am and stays at home, currently not working ( in the past , grocery storekeeper) and will have lunch at 1pm and takes rest and in the evening he will have dinner  and goes to bed  at around 9pm.

Family history: father has history of joint pains

 Drug history : 

no drug allergies and food allergies

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative. moderately built and nourished.

Pallor- present

Icterus- absent

Clubbing- absent 

Generalised lymphadenopathy-absent 

 Edema-absent 

Vitals:

Temperature- 98.3F

Pulse rate-86bpm regular, normal in volume

Respiratory rate- 18cpm

Blood pressure -140/90 mmhg

Spo2- 98%at room air 

SYSTEMIC EXAMINATION:

Cardiovascular system:

S1 and S2 heard no murmurs heard 

Central nervous system: 

No focal neurological deficit,

 cranial nerves intact.

Patient is concious coherent.

Motor 

   Tone- normal 

 Power- normal

 Cerebellar functions-normal 

Respiratory system: 

Bilateral air entry-present ,Normal vesicular breath sounds-heard

Abdominal examination: 

soft and non tender, No Hepatomegaly , spleen is not palpable

INVESTIGATIONS:

LFT:

HBsAg:

Serum iron:

Anti HCV Antibodies -rapid:

HIV 1/2 rapid test 

Random blood sugar:

Usg abdomen:

Hemogram:

Blood grouping and Rh type:

RFT :

ECG:

 

Usg neck

Surgery dept referral:

PROVISIONAL DIAGNOSIS: 

Chronic kidney disease on MHD

 ? secondary to NSAID  abuse 

K/c/o HTN.

Right IJV Thrombosis 

TREATMENT:

 4/12/22: