32yr old male case of CKD came for regular dialysis.

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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.

            BHUKYA GAYATHRI

            Roll no -22

           October20,2021.

      A 32yr old male presented to the casuality one month back with the chief complaints of seizures. Now came for the regular dialysis no other complaints. HISTORY OF PRESENTING ILLNESS:- 32yr old married male born out of non consanguineous marriage.He was apparently asymptomatic one month back then he developed seizures associated with increased urea level in the blood. No history of shortness of breath,pedal edema,decreased urine output

.PAST HISTORY:- No similar complaint in the past Patient is a known case of diabetes since 2yrs.No history of hypertension,asthma,Tuberculosis.No previous surgeries done.                      FAMILY HISTORY:- No significant family history.                                              PERSONAL HISTORY:- Diet:- mixed Appetite:-Normal Sleep:-Adequate No known drug or food allergy Drinks alcohol occationally.            GENERALEXAMINATION:- Patient was moderatly built and well nourished No pallor,icterus,cyanosis,clubbing, Lymphadenopathy,edema.        Temperature:-Afebrile.                  BP:-120/80 mmhg.                            PR:-96bpm

 SYSTEMIC EXAMINATION:-                   CVS:-S1 S2 heard No added murmers RESPIRATORY:-Bilateral airway is present. PER ABDOMEN:-Non tendor CNS:- patient is consious.Higher functions are intact.         PROVISIONAL  DIAGNOSIS:- chronic kidney disease with uremia.            INVESTIGATIONS:-                                   LFT:- Total bilirubin-0.78mg/dl.            Direct bilirubin-0.23mg/dl.                    SGOT-9 IU/L.                                            SGPT-4 IU/L.                                        Alkaline phosphate-166 IU/L.                  Total proteins-7.4gm/dl.                    Albumin-3.35gm/dl.                                    A/G ratio-0.83.                                          RFT:- Urea- 252 mg/dl.                    Creatinine-13.3 mg/dl.                              Uric acid-9.5 mg/dl                              Sodium- 134 mEq/l.                      Phosphorous- 6.9 mg /dl.           TREATMENT:- 

 Fluid restriction-1.5litres/day

 salt restriction- 2g/day LASIX- 40 mg BD Nodosis- 500mg BD 

 Insulin- 6 Units 

 Bio D3-500mg BD 

 Erythropoietin-1000IU/sc