A 50 years old male with CKD

April 11,2022

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. 

A 50 years old male came with a complaint of chronic kidney disease on maintenance hemodialysis since 1 year, pedal edema and shortness of breath since 1 week. 

HISTORY OF PRESENT ILLNESS :-

Patient was apparently asymptomatic 1 year back. Later he suffered with chronic kidney disease on maintenance hemodialysis.
He has a history of pedal edema and shortness of breath since 1 week. 

HISTORY OF PAST ILLNESS :-

History of hypertension since 2 years. 
History of DM since 1 year. 
No history of Tb/asthma.

PERSONAL HISTORY :-

Diet - Mixed
Sleep - normal
Appetite - normal
Addictions - none
Allergies - none 

FAMILY HISTORY :-

No relevant family history. 

GENERAL EXAMINATION :-

Patient is examined under well lit room amd adequate ventilation with his consent taken. 

Patient is conscious, coherent and cooperative, well oriented to time space. He is moderately built and well nourished. 

No visible pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.

Vitals :-

Temperature - 98.6
Blood pressure - 120/80 mm Hg
Pulse rate - 82 bpm
Respiration rate - 18 cycles/min
Spo2 - 98%
GRBS - 101 mg%

SYSTEMIC EXAMINATION :-

Cardiovascular system -
S1 and S2 sounds are heard. 
Respiratory system -
Central position of trachea. 
No wheeze, no dyspnoea. 
Central nervous system -
No neurological defects. 
Abdomen -
Scaphoid, no tenderness. 

INVESTIGATIONS :-

Ultrasound report :
Complete urine examination :
Complete blood picture :
Blood sugar level :
RFT :
Liver function test :
Ecg :
TREATMENT :-

Inj erythropoietin 4000 IU SC once weekly
Tab Nicardia 20mg BD
Tab Nodosis 500mg BD
Tab Lasix 40mg BD
Tab Shelcal 500mg OD
Tab Arkamine 0.1  PO TID

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