This is an online e-log book to discuss our patient de-identified health data shared after taking his / her / guardian's signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.
This E blog also reflects my patient-centered online learning portfolio and your valuable input in 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 coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.
Cheif complaints : 60 year old male presented with cheif complaints of vomitings and loss of appetite, generalized itching 5 days back
Hopi:
Patient was apparently asymptomatic 6 years back and then he developed joint pains in the great toe and proximal interphalengeal joint and had migrating joint pains and was diagnosed as gout in their regional hospital and was found that creatinine was increased, he used allopathy medication and ayurvedic medication for gout, he was on medication (?)for kidney problem for few years and stopped,
4 months back he developed generalized itching over the body, anorexia,epigastric pain, vomitings which is non billious with food particles in it and he went to regional hospital where he was diagnosed as ckd creatinine (6.2 mg/dl) and underwent 2 sessionsof dialysis and he developed infection
after dialysis (central line induced) and he was admitted in icu for one day and treated,
he had h/o of low grade fever since one month with chills and rigors since one month which is continuous subcided on using medication, h/o of constipation since many years, dry cough since 2 months, itching subcided after dialysis and recurrent itching episodes were present for which he used medication and it got subcided ,
since one week he is having diarrhea, anorexia, weakness and admitted in kamineni and he is on medication (?)of ckd since 5 days and yesterday he was admitted for dialysis
Past history:
Patient is hypertensive since 7 years
Not a known case of diabetes
No h/o of seizures, tb, leprosy
PERSONAL HISTORY:
Diet-mixed
Appetite-normal
Sleep-decreased
Bowel and bladder movements- has constipation
Addictons- occasional drinks alcohol 180 ml
Family history: father has history of joint pains
Drug history : no drug allergies and food allergies
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative. moderately built and nourished.
Pallor- present
Icterus-absent
Clubbing-absent
Cyanosis-absent
Generalised lymphadenopathy-absent
Pedal edema-absent
Vitals:Temperature- 98.3F
Pulse rate-86bpm regular, normal in volume, no raido radial delay, no radio femoral delay
Respiratory rate- 18cpm
Blood pressure -140/90
Spo2- 98%at room air
SYSTEMIC EXAMINATION:
Cardiovascular system:
S1 and S2 heard no murmurs heard
Central nervous system:
No focal neurological deficit, cranial nerve
intactCentral nervous system:
Patient is concious coherent.
Higher mental status-
Cranial nerves- intact
Motor
Tone- normal
Power- normal
Cerebellar functions-normal
Respiratory system:Bilateral air entry-present ,Normal vesicular breath sounds-heard
Abdominal examination: soft and non tender, No Hepatomegaly, spleen is not palpable
INVESTIGATIONS:
Ultrasonography:
Treatment:
Provinsional diagnosis: chronic kidney disease on MHD
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