This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians signed informed consent. 

Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence based input.

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

CASE SCENARIO:

A 53 year old male patient came to the hospital for Dialysis 

History of Presenting Illness:

The patient was asymptomatic 4 years ago. 3 years back the patient went to a medical practitioner with complaints of shortness of breath and fatigue, malaise, loss of appetite and fatigue. Patient was diagnosed with kidney failure on one side. The patient was given medication to sustain kidney failure. The patient continued his medication for kidney failure which he eventually stopped after a year. 

One month back, the patient went to a hospital with chief complaints of headache, fever and pedal oedema. He was admitted there and was diagnosed with CKD. He underwent 4 dialysis procedures there. The patient came to the hospital and underwent further 9 dialysis till date. 

History of Past Illness:

3 years back, the patient was diagnosed with Tuberculosis and was given drug therapy (ATT) for 6 months. He was cured. One month back the patient was again diagnosed with recurrent Tuberculosis and drug therapy is being given. 

1 year ago, the patient met with a bike accident. Since then, the patient claims to have neck stiffness. 

Patient has a history of HTN since one month. 

Personal History:

• married
• mixed diet 
• loss of appetite since the past month 
• discomfort in sleeping since 2 days 
• Patient had a history of alcohol intake. He used to drink half a bottle everyday and then stopped taking alcohol 3 years ago. He drinks it occasionally now. 
• Patient had a history of smoking 2 to 3 cigarettes per day which he stopped 3 years ago. 

Family History: Not significant 

Treatment history:

For reactive TB, a combination therapy with isoniazid, rifampin, pyrazinamide and ethambutol is being given. 

General Examination:

Pallor -

Icterus -

Clubbing -

Cyanosis - 

Lymphadenopathy -

Edema - pedal edema seen until the ankle 

Vitals:

PR: 96 bpm

BP: 130/90 

SpO2: 97%

RR: 40 

Systemic Examination:

 

CVS:

The chest wall is bilaterally symmetrical 

S1, S2 heard ; no murmurs 

CNS:

Patient is conscious, coherent and cooperative

R/S: 

Central position of trachea 

Bilateral crests are heard in all areas 

https://youtu.be/584IkrZ1XR4

 PROVISIONAL DIAGNOSIS: CKD on Hemodialysis