CKD case

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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 a diagnosis and treatment plan

    A 50 yr old Male farmer by occupation resident of miriyalaguda came to hospital with chief complaints of fever (with chills and rigor)and altered sensorium since 1week.

 Patient was apparently asymptomatic 6 years back then he got injured with a throne pick on right leg as it was not healed he went to the hospital on infestation he was diagnosed with Diabetes and hypertension.From that day onwards he is on medication.

2 yrs back complaints of bilateral pedal edema  insidious onset, gradullay progressive extented up to knee not associated with decreased urine output, facial puffiness, frothing urine.

Then patient was admitted in       hospital with chief complaints of pedal oedema and SOB . And on investigation he was diagnosed with Renal failure.5 dialysis sessions were done in 10 days. Then medications are given to the patient. 

After 8 months he developed vomitings and loose stools then he came to KIMS nkplly .Then he is on regular HD twice a week(since 1.5 yrs).

PERSONAL HISTORY 

Married 

Occupation : daily wage worker

Diet : mixed

Appetite : decreased

Bowel and bladder : Regular 

No addictions .

No known allergies .

FAMILY HISTORY 

K/C/O HTN , DM on medcation which are not known

GENERAL EXAMINATION 

Patient is altered sensorium

No Pallor, icterus ,cyanosis, clubbing , lymphadenopathy , edema.

VITALS 

TEMP : 98.6

BP : 130/ 84 mmhg

PR : 92/ min

RR : 20/ min 

SYSTEMIC EXAMINATION 

CVS : S1, S2 + 

RS : BAE + , NVBS 

P/A : SOFT , NON TENDER 

CNS : 

PATIENT IS conscious , coherent orinted to time ,place, person

SPEECH : normal

 

  

Diagnosis: Chronic kidney disease on maintenance Dialysis and acute pyogenic meningoencephalitis.