A 69 yr old male came to hospital for regular dialysis

This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them.

 65 y old male came admitted in hospital  for regular daislysis .

Chief complaints:

Facial puffiness, pedal odema,shortness of breath 

History of presenting illness:-

Patient was apparently asymptomatic 2 yrs back

The he suddenly developed fever,generalised weakness for which he visited local hospital.

After examination and investigations done 

Patient was diagnosed with hypertension and renal failure and was referred to another hospital in Hyderabad.

There he was treated with medications and patient was almost normal for an year and continued his daily activities.

After 1 yr patient stopped his medication and started consuming alcohol and toddy.

Then he developed symptoms of fever,severe facial oedema ,pedal oedema ,hypertension,shortness of breath,cough,oliguria,loss of appetite.

Now he again revisited the hospital in Hyderabad after examination and investigations he was diagnosed with complete renal failure and suggested to get dialysis done .

Patient came to narketpally and admitted here and have been undergoing dialysis since 8 months.

Initially dialysis was done weekly once now dialysis is done for every 2 days.

Past history:

Not a known case of asthma,diabetes,tuberculosis, epilepsy.

He underwent hernia surgery 10 years back

Family history:

No significant family history.

Personal history:

Decreased appetite, mixed diet, regular bowel movements, decreased urine output, adequate sleep, no smoking, daily consumption of toddy and alcohol.

Vitals:

BP: 140/90 mm Hg

Pulse: 80 bpm

Afebrile temperature 

General examination:

Pallor: present

Icterus: absent

No lymphadenopathy

No clubbing

Pitting oedema is seen

Diagnosis: chronic kidney disease on regular dialysis