A 46 year old male patient working in welding shop came for hemodialysis

General medicine E-Blog

Hi, I am N .Annmaria  , 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:

Shortness of breath( grade 4) since 10 days
Bilateral Pedal edema which is pitting type since 2 months

HISTORY OF PATIENT ILLNESS

Patient was apparently asymptomatic 6 months back. Then he developed bilateral pitting type pedal edema upto knees. It is associated with facial puffiness. 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.

HISTORY OF PAST ILLNESS

Known case of CKD since 3 months
Known case of Hypertension since 6 months and on medication
Known case of type 2 Diabetes since 8 years and on medication

TREATMENT HISTORY

He took treatment for diabetes and hypertension.
He also took treatment for tuberculosis 10 years ago.

PERSONAL HISTORY

Married 
occupation: gas welding
Diet: mixed
Appetite:normal
Sleep: normal
Bowel: irregular
Bladder: normal micturition
No known allergies
Addictions: alcohol but stopped 3 years ago

FAMILY HISTORY 
No significant family history.

PHYSICAL EXAMINATION

GENERAL EXAMINATION 
conscious and coherent
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: 98.4°F
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
Reflexes
No finger nose in coordination and knee heel incordination
INVESTIGATIONS:
AntiAnti HCV antibodies- Rapid
Hemogram
Complete urine examination
2D Echo
USG-abdomen
Random blood sugar test
ABG
Liver function test
RFT
Serum iron
ECG
HEMODIALYSIS DONE ON 27/82022 AND 28/8/2022
MEDICATIONS GIVEN

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