42 Y Male with CKD and on dialysis

 15th July 2023

NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.

This is the case of a 42-year-old male, resident of Nalgonda, and Labourer by occupation. The following history was taken with the patient in person. The patient was explained about confidentiality and written consent was taken to create the following case report.

This case report aims to record the patient's journey.

CHIEF COMPLAINTS:- 

-Came for regular dialysis as per schedule. 

History of present illness:- 

Pt was apparently asymptomatic 4 years back. Afterwards, he had consistent episodes of vomiting (frequecy the patient doesn't remember) and pitting type edema on both ankles. He went to a local hospital where he was diagnosed with CKD. He was on injection since 2 years (name unknown). The patient also had grade 2 sob and generalised weakness during the same period of time. 

No H/O of chest pain, palpitations, cold, fever, cough. 

DAILY ROUTINE:-

Patient follows a sedentary lifestyle. He generally wakes up at 6:30 am and has breakfast which generally consists of milk, on 7am. Later he has lunch which mainly consists of rice at around 11:20am. The patient generally doesn't have dinner

History of past illness:-

The patient has HTN since 3 years. 

The patient does not have any history of DM, TB, Epilepsy, and asthma.

Surgical history

No significant surgical history. 

The patient has been undergone blood transfusion approximately 12 times since his dialysis started. 

Personal history:-

Water intake:- half a litre per day

Appetite:- reduced

Diet:- mixed 

Bowel movement:- normal

Bladder movement:- normal

Alcohol:- occational consumtion for fifteen years. Stopped consumption since 9 months ago. 

Smoking:- nil

Addiction:- nil

Allergies:- nil

Exercise status:- moderate

FAMILY HISTORY:-

- not significant. 

PHYSICAL EXAMINATION:-

GENERAL EXAMINATION:-

The examination was conducted at a well lit and well ventilated room. The patient was conscious, cooperative and coherent. 

Moderately built

Afebrile

Considerable Palor observed

No Icterus

No Cyanosis

No Clubbing 

No Pedal edema

No Significant lymphadenopathy

CLINICAL PICTURES:-

REPORTS:-