E log

 CKD IN 15YRS OLD BOY 

Greetings to one and all who are currently reading my blog.  This is Jasmisri,third semester medical student

This is an online E - log book to discuss our patients 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 also reflects my patient-centered online portfolio and your valuable inputs on the comment box.

Case:-

    15yrs old boy was bought to the casualty with shortness of breath,pedal edema, decreased urine output. 

*Following link has previous case log of same patient 2 months back..


CHIEF COMPLAINTS:-
  • Shortness of breath 
  • Pedal edema
  • Decreased urine output
  • Vomiting  
  • Coughing 
HISTORY OF PRESENT ILLNESS:-
  • Shortness of breath since 10days (grade 2-grade3) 
  • Cough leading to chest pain
  • Pedal edema and decreased urine output since 5 days
  • Vomiting after intake of food with food particles 
  • Chronic kidney disease on maintenance hemodialysis  (2 months) 
  • First,he went to hospital near to his house due to fever, SOB,vomiting.On scanning it was declared as kidney failure then he  went to Hyd he had his first 5 dialysis then came to narketpally for further dialysis (near to his house) 4 months back. 

HISTORY OF PAST ILLNESS:-

Hypertension (2months)

PAST HISTORY:-

No h/o similar complaints before.
No known comorbidities.

PERSONAL HISTORY:-

  • Single ,student (9th grade) 
  • Appetite: Loss of appetite
  • Diet:veg
  • Bowels regular
  • Micturition normal
  • No allergies   

FAMILY HISTORY :-

  • No family history 
GENERAL EXAMINATION:-

  • Pallor
  • No icterus
  • No cyanosis
  • No clubbing
  • No lymphadenopathy
  • Pedal edema.
Vitals:-
  • Temp- afebrile
  • PR:99BPM.
  • RR: 18CPM.
  • Bp: 140/80 mm Hg
  • Spo2 : 99%
  • GRBS 151 MG%.
SYSTEMIC EXAMINATION:-

A. Cardiovascular system 
  • S1 S2 HEARD
  • NO MURMURS.
B. Respiratory system 
  • NVBS heard
  • BAE +
  • TRACHEA CENTRAL.
C. Per abdominal examination 
  • SOFT
  • NON TENDER
  • Scaphoid
  • BOWEL SOUNDS ARE PRESENT 
D. Central nervous system:-
  • Conscious 
  • Speech normal
  • Cranial nerve-NAD
  • Motor system-NAD
  • Sensory system-NAD
  • Cerebellar system-NAD
  • No signs of meningial irritation/ meningitis

INVESTIGATIONS:-

RFT:-


LFT:-Low albumin 



BLOOD GROUP:-


COMPLETE URINE EXAMINATION :-Albumin is excreted in urine.



COMPLETE BLOOD PICTURE:- low hb and other parameters varies inbetween normal ranges. 

AT 8:10pm

AT  2:58pm

ECG:-


USG REPORT:- 
ON 27-12-22

IMPRESSION:-
RIGHT -GRADE 1-RENAL PELVIC DIALATION
LEFT -GRADE 2-RPD

USG REPORT ON 28-12-22
IMPRESSION:-
BILATERALLY GRADE 2 RPD





SEROLOGY:-

HBsAg


HIV


HCV



PROFESSIONAL DIAGNOSIS:-

Chronic kidney disease on maintenance hemodialysis  

TREATMENT:-
Rx
Inj AVIL
Inj HYDROCORT
Inj IRON SUCROSE 1 Amp in 100 ml of NS in dialysis 
Oxygen mask
Fluid restriction (< 1 l /day)
Salt restriction (<2.4 mg /day)
TAB NODOSIS 500 mg PO/BD
TAB SHELCAL 550 mg PO/BD
TAB OROFER XT PO/OD
TAB LASIX 40mg PO/OD
TAB NICARDIA 20mg PO/TID
Inj ERYTHROPOIETIN 4000 IV/SC WEEKLY








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