60 yr old male patient with renal failure

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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.

A 60Years old male patient Occupation by farmer, resident of nalgonda came to opd with the chief complaint of :- 
Routine follow up for renal failure On haemodialysis

History of present illness :- 
Patient was apparently asymptomatic 10 yrs back then he had developed fever , difficulty in having food and was taken to hospital and incidentally found to have Diabetes mellitus And started on conservative management 
3yrs back Pedal edema , facial puffiness And was not treated for it 
2 yrs back Taken to local RMP And was diagnosed to have renal failure Used conservative medication but was not controlled 
15 days back Decrease apettite , vomiting nausea, facial puffiness, pedal edema, Distention of abdomen , decresed Urine output 

History of past illness :- 
Known history of HTN Since 1 year and on irregular medication (tab nicardin -10 mg) 
No known history of Asthma, Lymphadenopathy, tb, epilepsy 

Personal history :- 
Diet :- mixed 
Apetite :- Decreased 
Sleep :- adequate 
Bowel and bladder movements :- irregular 
Micturation :- abnormal 

Habits :- no addictions , beedi stopped 5 yrs backs 

Family history :- not significant 

General examination :- 

Patient is conscious, coherent, cooperative and well oriented to time, place and person.
No Pallor
No Icterus
No Clubbing
No Cyanosis
No Lymphadenopathy
No Edema of feet
No Malnutrition

Vitals:-
Temperature-98.6 F
Pulse rate-104 bpm
RR-32 cpm
BP-130/80 mm/hg
SPO2-98% at room temperature



SYSTEMIC EXAMINATION:

CVS- S1 S2 heard
No thrills and murmurs 

RS- 
Trachea central
BAE+

Abdomen: 
Distention of abdomen 
No tenderness
No palpable mass
Liver and spleen not palpable 


CNS: conscious &alert


Investigations :- 
ECG 

Haemogram 
Blood urea 
Serum iron 
Serum creatinine

LFT 

Chest x- ray :- 



Provisional diagnosis -Chronic kidney disease ? On mhd,Diabetic nephropathy 

Treatment :- haemodialysis
Tab  nodosis 500mg 
Tab nicardia. Retard 10 mg 
Tab shelcal 1 OD
Inj Iron sucrose 100mg +100ml NS IV once weekly
Tab lasix 40 mg Po/BD
Fluid restriction less than 1 lit / day 
Salt restriction less than 1.2mg per day 






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