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67 year old male patient with CKD 

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

Note: This is an ongoing case, the E-LOG will be updated as and when we get the new information.


HISTORY OF PRESENTING ILLNESS:

A 67 year old male patient was presented to the opd with cheif complaints of:
  • inablity to urinate and defecate
  • shortness of breath

HISTORY OF PRESTENTING ILLNESS:


A 67 year old male patient was presented to the OPD with cheif complaints of Iinablity to urinate and defecate ( defecation only twice a week) , shortness of breath and mild fever.
no h/o cough or pain in abdomen
no h/o vomitings 

HISTORY OF PAST ILLNESS:

h/o Diabetes mellitus -  since 20 years
h/o hypertension - since 6 months

FAMILY HISTORY :

no h/o any diseases


PERSONAL HISTORY :

diet :  non vegetarian
 non smoker
non alcoholic

GENERAL EXAMINATION:

conscious and choherrent
moderately built and moderately nourished.

pallor: absent
icterus: absent
cyanosis : absent
clubbing: absent
edema : absent
lymphadenopathy: absent

VITALS:

BP: 120/70 mmHg

PR: 80 bpm



Systemic Examination:

CVS:
inspection:
  • chest wall is bilaterally symmetrical
  • no visible pulsations,engorged veins, scars and sinuses
palpation;
  • jvp: normal
  • apex beat: felt in 5th intercoastal space in mid clavicular line
auscultation:
  • s1 s2 heard
  • no murmurs
RESPIRATORY:
  • central position of trachea
  • bilateral air entry: positive
  • normal vesicular breath sounds are heard
  • no added sounds are heard
PER ABDOMEN:
  • abdomen distended, soft and non tender.
  • bowel sounds heard
  • no palpable mass or free fluid

CNS:

  • no focal neurological deficits

INVESTIGATIONS:

RENAL FUNCTION TEST:




COMPLETE BLOOD PICTURE:



HCV TEST:




BLOOD GROUPING:




HIV TEST :





ULTRA SOUND REPORT :




DIAGNOSIS: 

Chronic Kidney Disease on MHD

PLAN OF CARE:

maintenance haemodialysis

Blood transfusion ( occured on 10/7/21 )


TREATMENT:

on 11/7/12

  1. fluid restriction < 2 L/day
  2. salt res triction < 2 gms/ day 
  3. Tab. Lasix 40 mg PO BD
  4. Tab. shelcal 500mg PO OD
  5. tab nodosis 550 mg PO OD 
  6. Tab orolex XT PO OD 
  7. Tab Nicardia 10 mg PO BD
  8.  I/O charting
  9. GRBS charting 6th hourly
  10. BP charting 8th hourly
  11. Inj. HAI / s/c /
on 12/7/21

  1. fluid restriction < 2 L/day
  2. salt res triction < 2 gms/ day 
  3. Tab. Lasix 40 mg PO BD
  4. Tab. shelcal 500mg PO OD
  5. tab nodosis 550 mg PO OD 
  6. Tab orolex XT PO OD 
  7. Tab Nicardia 10 mg PO BD
  8.  I/O charting
  9. GRBS charting 6th hourly
  10. BP charting 8th hourly
  11. Inj. HAI / s/c /
  12. inj ceftriaxone 1mg IV BD
  13. inj pan 40mg IV OD

on 13/7/21

  1. fluid restriction < 2 L/day
  2. salt res triction < 2 gms/ day 
  3. Tab. Lasix 40 mg PO BD
  4. Tab. shelcal 500mg PO OD
  5. tab nodosis 550 mg PO OD 
  6. Tab orolex XT PO OD 
  7. Tab Nicardia 10 mg PO BD
  8.  I/O charting
  9. GRBS charting 6th hourly
  10. BP charting 8th hourly
  11. Inj. HAI / s/c /
  12. inj ceftriaxone 1mg IV BD
  13. inj pan 40mg IV OD

on 14/7/21



  1. fluid restriction < 2 L/day
  2. salt res triction < 2 gms/ day 
  3. Tab. Lasix 40 mg PO BD
  4. Tab. shelcal 500mg PO OD
  5. tab nodosis 550 mg PO OD 
  6. Tab orolex XT PO OD 
  7. Tab Nicardia 10 mg PO BD
  8.  I/O charting
  9. GRBS charting 6th hourly
  10. BP charting 8th hourly
  11. Inj. HAI / s/c /
  12. inj ceftriaxone 1mg IV BD
  13. inj pan 40mg IV OD
  14. inj erythropoietin 1000 units weekly twice
HEMODIALYSIS CHART


































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