50yr old with loin pain

 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 evident based input.This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have 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.

 A 50 yr old male patient, buisnessman by occupation and a resident of nalgonda came to our hospital for regular checkup and dialysis.

HOPI: The patient was apparently asymptomatic one year back then he started having pain in the left lower back(left loin). It was insidious in onset, gradually progressive, continuous and dragging pain with no aggravating and relieving factors which lasted for 3 months.

Pain was associated with burning micturition at the beginning and end of urination.the urine flow was obstructed but the frequency and urge to urinate increased.Urine output was decreased.the urine was yellow coloured.

History of indigestion and vomiting which were projectile, non bilious aggravated on food intake and the contents was food particles .

The patient became very weak and couldn't even stand or perform his daily activities so he was put on dialysis.He is on dialysis 2 times a week from May 2021.

Past history: History of kidney stones in the right kidney 30 years back.

Known case of HTN Since 1year

Not a known case of diabetes, asthma, TB and epilepsy.

H/o use of ayurvedic medication for similar complaints in the past.

Personal history:

Diet-mixed 

Appetite-normal 

Sleep-adequate 

Bowel nd bladder-regular 

Addictions-nil 

General examination:

Pt was consious,coherent and cooperative 

Well oriented to time,place and person

Pallor -

Icterus -

Clubbing -

Cyanosis -

Lymphadenopathy -

oedema + 

Vitals

Temp: afebrile

PR- 80 BPM

RR- 17 CPMP

BP- 130/90

Systemic Examination:

RS: NVBS 

CVS - S1 &S2 +

P/A - soft and non tender 

CNS- NAD

Investigations:

RBS-101 mg/dl

Haemoglobin- 9.7 gm/dl

Serum creatinine- 7.3mg/dl

Blood Urea- 93mg/dl 

Oedema of left hand:

Fistula over left hand:

ECG:

2D ECHO:

USG:

Haemoglobin:

Random blood sugar

Serum creatinine 

Blood urea 

Provisional diagnosis and treatment:

 CKD on MHD.