THIS PATIENT DATA WAS GATHERED BY ROLL NO 21 AS PART OF HER COMPETENCE BASED LEARNING EVALUATION PORTFOLIO PREPARATION
* Date: 12/11/26
* Roll No: 21
* Batch: 2023
Patient Details
* Name: [DEIDENTIFIED]
* Age: 30 years
* Gender: Male
* Occupation: Shop owner (Shopkeeper)
* Address: [DEIDENTIFIED]
* Mobile No: [DEIDENTIFIED]
Clinical Notes
* C/O (Chief Complaints): Patient came for routine dialysis.
* HPI (History of Present Illness):
* It was apparently asymptomatic 1 year back, then patient developed vomitings.
* Sudden in onset, contents were food (3–4 episodes/day), then developed fever after 10 days gradually, associated with mild edema.
* Biopsy was done 1 year back.
Medical & Surgical History
* Past History:
* Similar complaints in past.
* Known case of HTN (Hypertension): 1 year.
* No known case of DM, TB, Asthma, epilepsy.
* Medication History: History of HTN drug usage.
* Surgical History: Not significant.
Personal History
* Diet: Vegetarian
* Addictions: Nil
* B & B (Bowel & Bladder): Normal
* Appetite: Normal (N)
* Sleep: Normal (N)
Family History
* Not significant
Here is the deidentified clean text transcription of the provided medical sheet:
* General Examination: Pt is conscious, well-oriented with time, place & person
* Temp: Afebrile
* BP: 120/90 mmHg
* PR: 86 bpm
* RR: 20 cpm
* Systemic Examination:
* CVS: S1, S2 positive (+)
* CNS: NFND (No focal neurological deficit)
* RS: BLA positive (+), NVBS (Normal vesicular breath sounds)
* PA: Soft, NT (non-tender)
* PIE (Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy, Edema): Negative (-)
* Fistula Examination:
* Scar present on 2 sites
* No pain at the site
* Provisional Diagnosis: CKD?
* Pt. Name: [REDACTED]
* Age: 30
* Sex: M
* I.P No: [REDACTED]
PROGRESS NOTES
* Tab. CONCOR COR 1.25\text{ mg} PO OD
* Tab. APRESOL 25\text{ mg} TID
* Tab. ARKAMIN 100\text{ mg} TID
* Tab. CILACAR 20\text{ mg} BD
* Inj. MERONEM 500\text{ mg} IV TID
* Tab. NODOSIS DS 1000\text{ mg} TID
* Tab. PRAZOPRESS XL 5\text{ mg} BD
* Tab. SHELCAL OD
* Inj. TARGOZID 400\text{ mg} IV OD
* Cap. SOMPRAZ D 40\text{ mg} OD
* EPOCET 6000\text{ IU} / 0.6\text{ mL} PFS – thrice a week (subcutaneous)
* UHID: [REDACTED]
* IPNO: [REDACTED]
* Patient Name: [REDACTED]
* Age/Sex: 30 Yrs / MALE
* Dept/Unit: NEPHROLOGY
* Req No / Lab No: 72
* Req. Date: 29-Oct-26 02:34 pm
* Collected On: 29-Oct-26 02:39 pm
* Reported On: 29-Oct-26 03:33 pm
* Authenticated On: 29-Oct-26 03:33 pm
DEPARTMENT OF CLINICAL BIOCHEMISTRY
Electrolytes (ELECTROLYTES REPORT)
* Sodium (Method: Direct ISE): 139 mEq/L (Biological Reference Intervals: 135 - 155)
* Potassium: 3.9 mEq/L (Biological Reference Intervals: 3.5 - 5.0)
* Chloride: 106 mEq/L (Biological Reference Intervals: 95 - 110)
RFT (RENAL FUNCTION REPORT)
* Random Blood Sugar (Method: God - Pod): 98 mg/dL (Biological Reference Intervals: 50 - 150)
* Urea (Method: Berthelot): 22 mg/dL (Biological Reference Intervals: 10 - 50)
* Creatinine (Method: Jaffes (Kinetic & End point)): 2.5 mg/dL (Biological Reference Intervals: Male - 0.9 - 1.5, Female - 0.8 - 1.3)
End of the report
* Patient Name: [DEIDENTIFIED]
* Age/sex: 30Yrs/MALE
* Dept/Unit: NEPHROLOGY
* Req. Date: 29-Oct-26 02:34 pm
* Collected On: 29-Oct-26 02:39 pm
* Reported On: 02-Nov-26 02:41 pm
* Authenticated On: 02-Nov-26 2:41 pm
DEPARTMENT OF PATHOLOGY
INVESTIGATION | RESULT | UNITS | BIOLOGICAL REFERENCE INTERVALS
CBC (COMPLETE BLOOD COUNT)
* Hemoglobin (Method: Cyanide free-Colorimetric Methode): 10.7 g/dL (M: 13.5-17.5 F: 12-15)
* TRBC COUNT (Method: Electrical Impedance): 3.7 millions/cumm (M: 4.5-5.5 F: 3.5-5.0)
* Total Wbc Count (Method: Electrical Impedance): 2,900 cells/cumm (4000 - 11000)
* Neutrophils: 78 % (40 - 80)
* Lymphocytes: 16 % (20 - 40)
* Eosinophils: 02 % (1 - 6)
* Monocytes: 04 % (2 - 10)
* Basophils: 00 % (0 - 2)
* PCV (Method: Calculated): 31.8 % (M: 40-50 F: 36-44)
* MCV (Method: Calculated): 83.9 fL (80 - 98)
* MCH (Method: Calculated): 28.2 pg (27 - 33)
* MCHC (Method: Calculated): 33.6 gm/dl (32 - 36)
* Platelet Count (Method: Electrical Impedance): 1.6 Lakhs/Cumm (1.5 - 4.5 lakh/Cumm)
* Suggested clinical correlation. If necessary kindly discuss
Here is a set of Socratic questions based on the case report to stimulate critical thinking and clinical reasoning for medical student learning:
1. History of Present Illness & Symptom Progression
* Question: The patient presented initially with sudden-onset vomiting (3–4 episodes/day of food contents) a year ago, and later developed a gradual fever after 10 days. Why is establishing the chronological sequence of symptoms (vomiting preceding fever) clinically significant in a patient with underlying renal impairment?
* Question: The patient is a known case of hypertension for 1 year. In a young adult (30 years old) presenting with advanced renal disease, how do you differentiate whether hypertension was the cause or the consequence of chronic kidney disease (CKD)?
2. Pathophysiology & Uremia
* Question: Persistent vomiting in the setting of chronic renal failure can be a manifestation of uremic syndrome. What are the primary mechanisms by which uremia affects the gastrointestinal tract and causes nausea and vomiting?
* Question: The clinical notes mention mild edema accompanying the presentation. How do failing glomerular filtration and impaired sodium-water handling lead to edema, and what cardiovascular complications can arise from this fluid overload?
3. Dialysis & Vascular Access Assessment
* Question: The patient is on regular dialysis and physical examination noted a fistula site with two scars and no pain. What are the key components of a routine clinical examination of an arteriovenous (AV) fistula, and what specific signs would suggest access failure, stenosis, or infection?
* Question: Given that this patient is undergoing regular dialysis and presented with a fever, what are the most common sources of infection in hemodialysis patients, and why must access-related sepsis be ruled out immediately?
4. Clinical Examination & Differential Diagnosis
* Question: The provisional diagnosis is Chronic Kidney Disease (CKD), yet general examination noted the patient was afebrile with normal vital signs (BP 120/90 mmHg, PR 86 bpm) during this specific visit. How does regular dialysis artificially normalize certain parameters like blood pressure and volume status, and why might inter-dialytic vitals differ significantly?
* Question: Aside from CKD secondary to hypertension or glomerulonephritis (noted by a past biopsy), what other structural or systemic etiologies should be considered in a 30-year-old presenting with end-stage renal manifestations?
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