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“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 reflects my patient centered online portfolio and your valuable inputs on the comments is welcome.”


A 45 year old male a daily wage labourer by occupation ,resident of nalgonda came to the opd 

CHIEF COMPLAINT

Dialysis(MHD) 

History of presenting illness

The patient was apparently asymptomatic 2 years  back when he had experienced weakness in right lower limb, upper limb and numbness in lips which initially stayed for half an hour.
Upon walking it relived but again presented the next morning,so was admitted to a hospital where it was  considered as cva revealed that he had high creatine levels and was treated
He was also diagnosed as denovo hypertension

He used tablet for three to four months in lieu of high creatine levels and discontinued after improvement of symptoms

2 months back he went to a hospital in nalgonda with complaints of shortness of breath,  and edema where he was deemed as chronic kidney disease and was required to do dialysis
He was referred to a hospital in hyderabad where he had dialysis 5 times

Then  1 month ago He came to our hospital for the dialysis and complaints of shortness of breath and pedal edema pitting type till knee 1 month 
He had 10 times dialysis

Now he has complaints of shortness of breath and pedal edema pitting type till knee  
And came for maintenance dialysis
He had dialysis till date 17


History of past illness
No history of Diabetes mellitus
                    Thyroid disease
                    Bronchial Asthma
                    Tuberculosis
He is a hypertensive since 2 yrs with inconsistent treatment
Stroke 2 years back? 

PERSONAL HISTORY
Married
Appetite-Decreased
non vegetarian
Bowels- adequate movement
Micturition- no complaints of decreased or burning micturation
Addictions- occasional alcohol consumption 
           smoking but stopped 2 months back(1-2 packs)back

Daily routine before 2 years
5:00 woke up
6-7:00 had breakfast
9:30 went to work
1:00 lunch
8:00 comes back and watches tv
8-9:00 dinner
9:30 sleep

Daily routine after pain
Stopped going to work
Still wakes up at 5  but then 
Eats and sleeps 
Sometimes watches tv

Dietary history
Breakfast- Dosa
Lunch rice and curry
Dinner rice and curry
Occasionally drinks a glass of milk

FAMILY HISTORY
No significance


General examination
The patient is conscious coherent and cooperative

Patient is thin with signs of muscle wasting

 Pallor is there

NO Icterus

NO Cyanosis

NO Koilonychia

NO Lymphadenopathy

PITTING TYPE OF EDEMA



VITALS

 Afebrile

BP :140/90 mmHg 

Pulse rate : 99

Respiratory rate : 18

SPO2 at room air :99% 



SYSTEMIC EXAMINATION 

CVS
NO Thrills 
S1 and S2 heard +
NO murmurs
 
RESPIRATORY SYSTEM
Position of trachea: central
NO wheeze
NO dyspnoea

ABDOMEN
Shape : Scaphoid
NO Tenderness

No palpable mass, fluid , bruits



CNS 
Higher functions intact
Patient is conscious, coherent,and co operative
Patient is oriented to time place person
No delay in response

Crainal nerve intact



Examination of motor system 
Tone normal
Power of muscle normal

Coordination of movement normal


 Provisional diagnosis

Chronic kidney disease on maintenance dialysis

INVESTIGATIONS










Treatment plan
Day 1

S :- 


O:-
Pt is conscious, coherent cooperative

Bp:-140/70
Pr:-92 bpm
Cvs:-s1s2+
R/s:-BLAE +
P/A:- soft , non tender spleenomegaly
CNS:- NAD

A:-



P:-

Vital monitoring
Temperature monitoring

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