46 year old male working in welding shop came for hemodiallysis

 Eblog 5

28/08/22

Hi, I am shaik karishma , 3rd Sem Medical Student.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-centered online learning portfolio and your valuable inputs on the comment box is welcome.”

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 a diagnosis and treatment plan. 

CHIEF COMPLAINTS

The patient came with SOB grade 4 and has bilateral pitting type of pedal edema since 6 months .

HOPI

the patient was apparently asymptomatic 6months back and then developed bilateral pedal edema which was pitting type and upto knees Associated with facial puffiness.then his baseline creatinine was 2.0 so he managed conservatively for 4 months. Then he went to urban hospital and was initiated to haemodialysis. Total 16 sessions of haemodialysis were performed and last session of haemodialysis was on 20/8/22

PAST ILLNESS 

CKD since 3 months

 Hypertension since 6 months and on medication

Diabetes type 2 since 8 years and on medication

TREATMENT HISTORY

diabetes yes 

Hypertension yes 

No CAD,asthma 

TUBERCULOSIS yes (10yrs ago )

No chemoradiation, blood transfusion and surgeries

PERSONAL HISTORY

Married

 occupation: gas welding

Appetite was normal

Mixed diet

Irregular bowel

normal micturation

He was alcoholic but stopped 3 yrs ago

FAMILY HISTORY 

No diabetes ,hypertension, CAD,stroke , cancer, TB ,asthma 

PHYSICAL EXAMINATION

GENERAL

conscious

pallor present 

No icterus

No lymphedemopathy

No clubbing of fingers

Edema present(pedal edema of pitting type with facial puffiness)


No malnutrition
No dehydration

VITALS
temperature afebrile
Pulse rate 78 bpm
Respiration 20/min
BP 150/70
GRBS 154mg%

SYSTEMIC EXAMINATION
CVS
no thrills
No cardiac murmers
S1 s2 present

RESPIRATORY SYSTEM
Dyspnoea present
No wheezing
Centrally placed trachea
Vesicular breathing sounds 

ABDOMEN
obese shaped
No tenderness and palpable mass
Normal hernial orifice 
No free fluid 
Normal bowel sounds
Liver and spleen not palpable

CNS
conscious 
Normal speech
No neck stiffness
No kerning's sign
Cranial nerves ,motor system ,sensory system ,Glasgow scale HMF(higher mental function) intact
No finger nose in coordination and knee heel incordination

INVESTIGATIONS
















Hemodialysis done on 27/8/22 and 28/8/22


MEDICATION

























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