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CKD ward, 38yr old male

 


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 patients 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 comment box is welcome.
38yr old male , works in a book stall 
HAS BEEN ON DIALYSIS SINCE 6YRS.

Yesterday night he came with
 c/o shorteness of breath ,pedal edema, abdominal distension and got admitted. 
He cannot walk on his own, needs support.
Yesterday's vitals:
Bp:140/90mmhg
RR: 28cpm
Spo2: 98% RA.

Today he has a dialysis session.
His last dialysis was about a month ago
He comes under day care basis usually.
He has AV fistula to his left arm.
H/O HTN since 2yrs on tab. NICARDIA 20mg.
Today mrng at 9:00am his 
BP : 190/110mmhg 
RR: 26cpm
After nebulization, sob decreased to some extent. RR: 20cpm.
After giving NICARDIA 20mg oral ,  after 1hr his BP came down to 150/90mmhg.

H/O alcohol since 20yrs, every alternate day around whiskey 200ml/day. Now since 2-3yrs he stopped consuming alcohol.

He is a smoker since 20yrs, smokes around 20-30 cigarettes per day, before 6yrs.

NOW HE SMOKES AROUND 10-12 CIGARETTES PER DAY

No H/O DM, EPILEPSY, THYROID, TB ASTHMA.

PAST HISTORY:
Occupation: book seller
Married. Has a healthy daughter with age of 10yrs.
He was apparently asymptomatic 6yrs back.
His daily routine was, he used to wake up around 7, undergo his daily natural activites, goes to book stall around 10, comes to house for lunch in the afternoon, goes back to work again. Though he was regular to his work, before 6yrs. He used to stay at home for almost 2-3 days a week.
In the evening with his friends around his house, consumes alcohol around 250ml a day whiskey.
Smokes around 20-30cigarretes per day.

Now he is not working, stays at home.

Before 6yrs, he went  to nearby hospital with complaints of loss of appetite since 1mon , pain abdomen, shorteness of breath , pedal edema.
Got diagnosed as renal failure and has been sent to our hospital for dialysis.
Since then he has been under dialysis.
In between he used to have episodes of shorteness of breath and pedal edema, got relieved after dialysis and by taking regular medication.

Before 2yrs he was been hospitalized with complaints of grade 4 shorteness of breath, pedal edema and pain abdomen.
He has been diagnosed DENOVO HTN.
On regular medication.
In his xray , plueral effusion was noted in left side.
3 times pleural tap was done.
1time PRBC Transfusion was done
and got discharged.
Continued dialysis sessions on day care basis.

Before 2months ,he developed abdominal distension, gradual in onset , progressive, not relieving.

INVESTIGATIONS:


















PROVISIONAL DIAGNOSIS:
CKD ON MHD .

PLAN OF CARE:
Fluid restriction<1lt/day
Salt restriction<2.4gm/day
Inj. Lasix 40mg i.v /TID
Tab. NICARDIA 20MG PO/TID.
Tab. SHELCAL po/od
Tab. Orofer xt Po/od
Inj.erythropoietin 4000IU S/C weekly once
Inj. Iron sucrose 1ampoule in 100ml NS during dialysis.





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