Case Discussion: CKD

 24/11/2021

Samhita Ghanathay

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58 year old male patient with complaints of reduced and burning micturition.

I've been given this case to solve, in an attempt to understand the topic of "patient clinical data analysis" to develope my competency  in reading and comprehending clinical data - including history, clinical findings, investigations - and come up with diagnosis and treatment plan.

Following is a brief about the case,

(History as per date of admission).

CHIEF COMPLAINTS: 

A 58 year old gentleman, from Nalgonda, came to the Medicine OPD about 15 days ago with chief complaints of :

• Reduced urine output since 4 weeks.

• Burning sensation during passage of urine        since 4 weeks.

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 4 weeks ago when he started suffering from reduced urine output which was sudden in onset and associated with burning micturition as well as fever(mild).

For this, he went to a local hospital where he was diagnosed to have kidney failure and was advised to have dialysis done.

He underwent 6 cycles of dialysis in a span of 1½ weeks after which he came to our hospital for another check up.

Here he was suggested to continue dialysis.

There were no aggrevating or relieving factors.

There was no history of Pedal Edema at any point in time. No history of pain abdomen or loose stools.

PAST HISTORY: 

• No history of similar complaints in the past.

• Not a known case of DM, HTN,Asthama, Epilepsy or TB.

• No history of surgery.

PERSONAL HISTORY: 

• Diet - Mixed

• Appetite - Normal

• Bowel and Bladder - Reduced urine output; burning micturition at the time of admission.

• Sleep - adequate 

• Addictions- alcohol consumption, about a quarter everyday since teenage;
• Tobacco chewing since teenage.

• No Allergies.

FAMILY HISTORY: 

In this case it is insignificant.

GENERAL EXAMINATION:

The patient is conscious,coherent and cooperative; well oriented to time,place and person.

She is sitting comfortably on the bed.

She is moderately build and well nourished.

• Pallor-absent 

• Icterus-absent

• Clubbing-absent

• Cyanosis-absent

• Lymphadenopathy-absent

• Edema - absent

Vitals: 

• Temperature -afebrile.

• Pulse rate - 80/ minute 

• Respiratory rate - 18/minute

• Blood pressure (left arm) - 120/70 mm of Hg

SYSTEMIC EXAMINATION:

CVS: S1 and S2 heard. No addded thrills or murmurs heard

RESPIRATORY SYSTEM:  

Normal vesicular breath sounds heard. 

ABDOMEN:

Soft and non-tender.

No organomegaly seen.

CNS:

Conscious and coherent.

Normal sensory and motor responses.

INVESTIGATIONS: 

The investigations ordered are: RBS, Blood Urea, Serum Creatinine, Serum electrolytes.

RBS :  

Blood urea: 

Serum Creatinine:

Serum electrolytes:

Hemoglobin :

USG: 

PROVISIONAL DIAGNOSIS: 

Acute kidney injury which may proceed to chronic kidney disease. Currently on dialysis.

TREATMENT: 

• Supportive care is given and patient maintained on hemodialysis

• Salt restriction < 2gm/day

• Fluid restriction < 1.5 L/day.

NOTES :

• The patient was advised to get dialysis done on a regular basis.

• If any puffiness encountered, asked to come to hospital immediately.