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-centred online learning portfolio and your valuable comments on comment box is welcome.
I've 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.
Name: Kattekola Sathwik
Roll no 58
2017 batch
A 61 year old male from rural telangana has presented with following history
Patient was apparently alright 3 years ago. Then he had loin pain which was insidious in onset and continuous. He went to a local hospital who then diagnosed Renal failure and was on medical management for 2 years with backline serum creatinine 3 mg/dL
On 8/9/2020 he went to a hospital in Hyderabad with complains of anorexia, dyspepsia,insomnia. He was then found to be having a serum creatinine of 21 mg/dL
Then Dialysis was started and he was on hemodialysis twice a week
Initially for 9 months dialysis was through right radial A-V fistula which failed subsequently
Then, hemodialysis through brachial A-V fistula was tried which also failed
Currently he is undergoing dialysis through Right Femoral line..
Past history
He is a known case of hypertension since 3 years on irregular medication
Not a known case of Diabetes, CAD, tuberculosis
No prior surgeries
Personal history
Appetite : Normal
Diet : Mixed
Bowel and bladder habits : regular
Sleep: adequate
No history of addictions and allergies
Family history : insignificant
General examination
Patient is conscious coherent cooperative
Well oriented to time place and person
Moderately built and nourished
Pallor absent
Icterus absent
Cyanosis absent
Clubbing absent
Generalised lymphadenopathy absent
Pedal edema absent
Vitals
Temperature : afebrile
Pulse: 82 beats per minute, regular rythm
Respiratory rate: 24 cycles per minute
Blood pressure:130/90 mmHg
Systemic examination
Respiratory system
✓The chest is elliptical
✓Moving equally on both sides with respiration
✓Apex beat seen and felt at 5 th intercostal space 1 cm to medial to mid-clavicular line
✓Bilateral air entry present
✓Trachea is central
✓Resonant note on percussion over the chest
✓Normal vesicular breath sounds were Heard.
Cardiovascular system
✓The chest is elliptical
✓Moving equally on both sides with respiration
✓Apex beat seen and felt at 5 th intercostal space 1 cm medial to mid-clavicular line
✓Heart borders were percussed
✓On auscultation, S1 S2 were heard
Per abdomen: soft, bowel sounds heard.
Central nervous system
✓Higher mental function normal
✓No signs of meningeal irritation
✓On examination,cranial nerves motor system and sensory system are normal
Investigations
ECG
USG-Abdomen
Soap notes
Date : 20/10/2021
Diagnosis : CKD on MHD (started on 9/9/2020) with known hypertension since 3 years on irregular medication
On examination
Patient is conscious coherent cooperative
Well oriented to time place and person
Pulse :84bpm
BP :130/70mmHg
CVS: S1 S2 heard
RS: BAE +
PA soft
CNS: NAD
Treatment
✓Fluid restriction <1.5L/day
✓Salt restriction,<2g/day
✓Tab.Lasix 40 mg PO-BD
✓Tab.Nodosis 500 mg PO-BD
✓Tab. Bio-D3 0.25mg PO-OD
✓Tab.Shelcal CT 500 mg PO-OD
✓Tab orofer xj PO-OD
✓INJ.ERYTHROPOIETIN 4000 IU s/c weekly once
✓Strict I/O charting
✓BP/PR/RR/SPO2 monitoring 4 th hourly
Date : 22/10/2021
Diagnosis : CKD on MHD (started on 9/9/2020) with known hypertension since 3 years on irregular medication
On examination
Patient is conscious coherent cooperative
Well oriented to time place and person
BP :140/90 mmHg at 8 am
100/70 mmHg at 8 pm
PR : 78 bpm
RR :18 cpm
CVS: S1 S2 heard
RS: BAE +
PA soft
CNS: NAD
Treatment
✓Fluid restriction <1.5L/day
✓Salt restriction,<2g/day
✓Tab.Lasix 40 mg PO-BD
✓Tab.Nodosis 500 mg PO-BD
✓Tab. Bio-D3 0.25mg PO-OD
✓Tab.Shelcal CT 500 mg PO-OD
✓Tab orofer xj PO-OD
✓INJ.ERYTHROPOIETIN 4000 IU s/c weekly once
✓Inj. Ceftriaxone 19/iv/BD
Date :24/10/2021
Diagnosis : CKD on MHD (started on 9/9/2020) with known hypertension since 3 years on irregular medication
Patient complained of decreased urine output
3 session dialysis done
On examination
Patient is conscious coherent cooperative
Well oriented to time place and person
PR :84bpm
BP :90/60 mmHg on Norad 4mL/hour..
CVS: S1 S2 heard
RS: BAE +
PA soft
CNS: NFD
Treatment
✓Fluid restriction <1.5L/day
✓Salt restriction,<2g/day
✓Inj.Ceftriaxone 1g iv/BD
✓Tab.Lasix 40 mg PO-BD
✓Tab.Nodosis 500 mg PO-BD
✓Tab. Bio-D3 0.25mg PO-OD
✓Tab.Shelcal CT 500 mg PO-OD
✓ Inj. Norad 2 ampules in 36 mL NS @6 mL/hr
Increased/decrease to.maintain MAP >65
✓ BP monitoring
✓ strict I/O charting
✓ Inj. PIPTAZ 4.5mg IV STAT @3pm followed by
Inj. PIPTAZ 2.25 mg IV TID
8am- 2pm-8pm
BP monitoring record on 24/10/2021
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