65 years old male patient came to OPD for dialysis

65 years old male patient came to OPD for dialysis

August 1st 2023.

This is an online e log book to discuss our patient de-identified health data shared after taking his /her guardian signed informed consent. Here we discuss our individual patients problems with collectors current best evident based input.

This E blog 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 diagnosis and treatment

This is the case of a 65 year old male resident of mirayalaguda presented to hospital for dialysis.

Chief complaints-

- patient came to OPD for dialysis on 27th July 2023

 

History of present illness-

     Patient was apparently asymptomatic 4 years back then he was constantly having fluctuating high BP  as he had shortness of breath and feeling fatigue so he consulted a doctor who prescribed tablets for rising BP for 1 year which reduced on taking medication. 

Later he developed puffiness of face and edema on legs. On consulting a doctor blood reports showed increased level of creatinine which aggregated on taking non-vegetarian food which was constant with medication.

4 years later he again started eating non- veg which lead to increase in creatinine level to 10.4 mg/dl on 26th June 2023. So he started dialysis for 4 consecutive days.He again came for dialysis on 27th July 2023 twice weekly.He also suffered from frequent urination with uncontrolled bladder movements. 

He suffered from fever along with chills on 1st August 2023  which was sudden in onset, non- progressive and relieved on medication with fluctuated BP. He also has generalised weakness after dialysis.

Negative history - 

No significant history of loose stools, vomitting,cough,cold,gliddiness, constipation,indigestion, blotting.

Past history - 

No HTN, TB, DM, asthma, epilepsy, CAD.

Personal history -

Diet- mixed

Appetite- normal 

Sleep- adequate 

Bowel and bladder movements - regular

No addictions.

Family history - 

No significant family history.

General examination -

I have taken prior conscent of patient.

Patient was examine in well lit room.

Patient is conscious , coherrent , co-operative, well oriented to time place and time.

Mild pallor .

No icterus, clubbing, edema, lymphadenopathy.

Provisional diagnosis -

Chronic kidney disease.

Investigation-