A15 year old male with CKD
Oct 26,Tuesday.
This is an online e log book to discuss our patient identified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient problems through a series of inputs from available global online community of experts with a aim to solve those patients clinical problem with collective current best evidence based inputs.
This blog also reflects my patient centered online learning portfolio and valuable inputs on the comments box is welcome.
I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation
A 15 year old male had come to the OPD with the chief complaints of shortness of breath since 4 hrs and was brought to hospital at 1am on 26th October night and vomiting since 1 month .
Patient is a student and his daily routine consisted of waking up at 6am and he goes to school , his average day work ends at 9 pm .
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 1 month back , then he developed vomitings with a frequency of 2 to 3 episodes per day,it was non projectile ,non bilious ,no foul smelling, consisted of food particles ,not associated with blood ,for around 1 month.
He complained of shortness of breath since yesterday night which was aggravated in supine position, grade 2, PND is absent .
It was associated with chest pain, which was a dragging type of pain and was present only during episode of sob.
No complains of palpitations , syncopal attack, decreased urine output,pedal edema ,facial puffiness.
There was history of fever 1month back associated with chills for 2 days and relived with medication.
Incidentally diagnosed to have high urea and high creatinine and went to Hyderabad where he was started on dialysis.5 sessions of haemodialysis was done.
Since then he was on dialysis.
PAST HISTORY :
He is a known case of hypertension( denovo hypertension incidental finding when he was admitted 1month back in hospital) since 1 month.
No history of DM ,TB ,Epilepsy, Thyroid
PERSONAL HISTORY:
Diet: Mixed
Appetite:Normal
Bowel movements:Regular
Micturition:Normal
No known allergies and addictions.
FAMILY HISTORY:
No significant family history.
GENERAL EXAMINATION:
Patient was conscious,coherent,cooperative moderately built and moderately nourished
He was examined in a well lit room after taking consent.
VITALS:
Pulse rate:96 bpm
Respiratory rate:24/min
BP:140/100mm Hg
Temperature:98 F
SpO2:86%
Physical examination:
Pallor:present
Icterus:not present
Cyanosis:not present
Clubbing:not present
Lymphadenopathy:not present
Generalised anasarca not seen
No edema
Systemic examination
CVS
S1 and S2 heard
No thrills and no murmurs
RESPIRATORY SYSTEM
Trachea is central in position
Dysnea
ABDOMEN
Scaphoid shaped abdomen
No tenderness
No palpable mass
No hernial orifices
No free fluid
Liver and spleen not palpable
Bowel sounds heard
CNS
Conscious and normal speech
Normal gait
Cranial nerves are normal
Sensory and motor system normal
Investigations
CBP
Provisional diagnosis
CKD
Plan of management:
Renal transplantation
Treatment
