MY LEARNING POINTS AND WORK IN NEPHROLOGY (FROM 27 /12/22 TO 31/12/22 )

 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.

Name : Supriya .K ( Intern ) 

Roll Number : 63 

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. 

MY IDEA OF MAKING BLOG IS -  WHY ONLY THEM NOT EVERYONE AFFECTED WITH KIDNEY DISEASE : 

SO, I THOUGHT OF SHARING NEPHROLOGY PATIENTS -DAILY ROUTINE , DIETARY HABITS , ENVIRONMENTAL FACTORS AND FAMILY HISTORY( so that this data could be useful to anyone to find the outcome ) INSTEAD SHARING RESPECTIVE PATIENTS CASE REPORT LINKS ,AS MOST OF THEM PRESENTED WITH SAME COMPLAINTS ( SOB with varying grades and pedal edema ) associated with K/C/O  HTN /DM or HEART FAILURE .

SO I LEARNT , MMRC Grading : ( Modified Medical Research Counsil Scale for Dyspnoea ) 

EDEMA (pitting ) Grading : 

DONE DETAILED  RESPIRATORY EXAMINATION (On patient in AMC ): 

Patient examined in sitting position

INSPECTION: 

-Chest  appears bilaterally Symmetrical and Elliptical in shape 

-Respiratory movements appears equal on both sides and it's Abdominothoracic type 

-Trachea -Central in position 

-Nipples - In 4th Intercostal space 

-No scars ,Sinuses , Engorged veins and visible pulsations 

No signs of Volume loss

PALPATION : 

-All inspectory findings confirmed

-Trachea -Central in position,No deviation 

-Apical Impulse - In Left 5th ICS , 1cm Medial to the Mid clavicular line 

- cricosternal distance : 3 finger breadth 

PERCUSSION: 

                                     Right                   Left 

Supra Clavicular :  Resonant        Resonant 

Infra Clavicular :   Resonant        Resonant 

Infra mammary :   Resonant        Resonant 

Axillary :                 Resonant         Resonant 

Infra axillary :       Resonant         Resonant 

Supra scapular :    Resonant         Resonant 

Inter scapular :     Resonant          Resonant 

Infra scapular :      Resonant         Resonant

AUSCULTATION :    

                                   Right                Left 

Supra Clavicular :   NVBS             NVBS 

Infra Clavicular :     NVBS             NVBS 

Infra mammary :    NVBS             NVBS 

Axillary :                  NVBS              NVBS 

Infra axillary :        NVBS               NVBS 

Supra scapular :     NVBS               NVBS

Inter scapular :       NVBS               NVBS 

Infra scapular :       NVBS               NVBS 

( NVBS - Normal Vescicular Breath Sounds ) 

No Fine / Coarse  Crepitations heard .

LEARNT ABOUT IMPORTANCE OF AV FISTULA: 

1) Rule of 6 For AV Fistula: 

Flow rate should be more than 600ml/min 

Vein diameter should be more than 6mm 

Vein depth should be less than 6mm 

2) Types of AV fistula : (AV fistula - Surgically Created in the Non- Dominant Hand ) .

Radial - Cephalic Fistula : anastomosis between Radial artery and Cephalic vein in the distal fore arm .

Brachial -Cephalic Fistula : anastomosis between Brachial artery and Cephalic vein in the Proximal Fore arm 

Brachial -Basilic Fistula : anastomosis between Brachial artery and Basilic vein in the upper arm .

3) Maturation of AV fistula : requires 4 to 6 weeks , (on  an average varies acc to pt from 1 to 4 months 

4) Complications of AV Fistula: 

Heart Failure is the serious complication of large AV Fistula . 

Claudication - due to lack of blood supply to legs 

Internal bleeding 

LEARNT ABOUT HEMODIALYSIS AND ITS EQUIPMENT: (Session Duration max : 4 Hours ) .

Acid and bicarbonate solutions(specific to hemodialysis ) are used as Dialysate . Its composition varies from patient to patient according to their electrolytes and pt condition.(we can correct Na+ through machine and also through Dialysate) can't correct K+ through Machine but  only through Dialysate .

Rule of 7 for Dialysis: 

The K+ level  in the patient's body and the K+ given through the dialysate should be equal to 7 (on adding both) .(K+ level in the dialysate adjusted acc to the patient K+ level ) .

If patient complaints of SOB during the session ,then we can stop water access ,through the machine , that may decrease the load in patient . 

(Or ) can give medications (diuretics ),if it's severe .

Monitored vitals during the session: when patient lands in hypertension ,managed through medications like Nicardia 20mg ,lasix 80mg ,labetalol 10mg  acc to pt condition . 

Temperature maintained -36.5 °C , Flow rate : 500ml/min .

2ml heparin is diluted with 8ml of NS ,initially 6ml of this solution is given as bolus later during the session ,given as  2ml and 2ml (it's automatically taken by the machine during the session) if not ,can be given manually also .

ASSISTED To Dr .Chandana Ma'am in CENTRAL LINE ( done  activities like Cleaning and draping , suturing) and maintained sterile environment while doing it .Learnt about catheterization. (IJV and femoral vein) .

Monitored vitals of patients in CKD ward ,on daily note  and Managed their Hypertension and DM (According to their GRBS values ) .

LIFESTYLE OF DIFFERENT PATIENTS IN NEPHROLOGY (BEFORE THIS EVENT) :  

(Daily Routine, Dietary habits , Environmental Factors ,Family History ) 

1) 47YRS OLD MALE PATIENT from choutuppal ,Lorry driver by Occupation ,diagnosed with AKI ON CKD 

K/C/O HTN since 1 year (on Medication) 

H/O CVD 1year ago (stenting done ) 

Daily routine :  

As he is lorry driver by Occupation, goes to work for 15-20 days to long distances , wakes up at 4:00 AM  ,have tea frequently with one hourly duration,No habit of having breakfast in the morning , he cooks his own food with ingredients (brought from home ) and have his meals at around 3 PM , have Drinking water only (not preferred other source of water ) and travels asusual and have dinner at around 10PM .

He worked as Labourer in fields with Iron as Constituent at  Karnataka for 1 year (2006 year) @2 months at a stretch without going to his home place , According to patient ,working in those fields ,affected his health and made him physically weak . So  Stopped  it and continued as Lorry driver

Daily routine,when he is at Home for 15 days (when worked as Lorry driver) 

Wakes up at 7:00AM -have tea ,at around 10AM - have Roti and Tea  ,he takes rest and spends with family and friends (this whole 15days )  at around 1PM - have meals and tea ,at around 5PM - have tea at around 8PM - have meals /roti , at 10PM - he Usually sleeps .

Dietary habits - Mixed (Non allergic to any food) 

-Have water @ 1 litre / day 

-occasional alcoholic

- smoker : 1 Pack of  Beedi /day since 25 years 

Environmental factors:  from Choutuppal, Nalgonda district ( tropical region ) 

Family History: No H/O any Kidney disease in family but H/O DM and HTN present .

2) 60 YRS OLD MALE PATIENT from Suryapet ,Merchant by Occupation since 15 years , previously he was farmer ,Diagnosed with AKI on CKD 

K/C/O HTN (DENOVO DIAGNOSED 1 month ago ) - On medication .

On dialysis 

Daily Routine: 

wakes up at 7AM - Usually have tea and snacks in the morning and goes to work ,at around 2PM - have meals  , around 5PM - have tea ,at around 9:30PM - have dinner (meals ),and sleep  .(when he was farmer used to wake up at 6 AM , and used to have meals at 9AM and goes to farm ).

Dietary habits : Mixed diet (not allergic to any food)

Have water @ 2 litres /day 

Non alcoholic

Non smoker 

Environmental factors: from Suryapet ( tropical region) 

Family History: No H/O kidney diseases in the family but H/O HTN+ 

3) 60YRS OLD MALE PATIENT,from Mothkur , labourer by Occupation, diagnosed with CKD on MHD 

K/C/O HTN since 2 months (On medication) 

K/C/O CKD since 6 months (on dialysis) 

Daily routine : 

Wakes up at 6AM - have tea ,at around 9AM - have meals and goes to work , at around 2PM- have meals ,takes rest for sometime then goes to work again and returns home and at around 8PM have meals and at 10PM  he usually sleep .

Dietary habits : Mixed diet (non allergic to any food 

-Have water @ 3 litres /day 

Occasional alcoholic

Smoker : 4-5 beedi /day since 20 years 

Environmental factors:  from Mothkur (tropical region ) 

Family History: No H/O any Kidney disease and No H/O HTN and DM 

4 ) 70YRS OLD MALE PATIENT, from Choutuppal,POT MAKER by Occupation, Diagnosed with CKD 

K/C/O HTN and DM since 2 years (On medication) 

On dialysis 

Daily routine: 

Wakes up at 6AM ,have tea goes to work  and 10AM -have meals and goes to work ,at around 2PM in the afternoon - have TODDY and sleeps and most of the time he directly wakes up in the next day morning, occasionally wakes up in the night and have dinner (meals ) 

Dietary habits - Mixed diet (non allergic to any food 

Have water @ < 1 litre/day 

Occasional alcoholic (regular toddy drinker ) 

Smoker : 1 pack of Beedi /day since 20years 

Environmental factors : from Choutuppal, Nalgonda district (tropical region) 

Family History: No H/O kidney diseases,HTN ,DM 

5) 50YRS OLD MALE PATIENT, from Kaeshvarigudem , Farmer by Occupation, diagnosed with CRF 

K/C/O HTN since 1 year (On medication) 

On dialysis 

Daily routine: 

Wakes up at 5AM and Goes for prayer and at 6AM have tea and at around 8AM have meals and goes to farm and at 1PM have meals and takes rest for sometime and goes to work again and returns home at around 6PM and have dinner (meals ) at 8PM and goes to bed after dinner .

Dietary habits : mixed diet (non allergic to any food) 

Have water @ 4litres/day 

Non alcoholic

Non smoker 

Environmental factors: from Kaeshvarigudem,Nalgonda district (tropical region)

Family History: No H/O kidney disease ,HTN,DM 

6) 60YRS OLD MALE PATIENT, from Battugudem , Farmer by Occupation, Diagnosed with CKD 2° to Diabetic Nephropathy 

K/C/O DM since 10 years , HTN since 5 years (On Medication ) ,CKD since 1 year 

On dialysis 

Daily routine : 

Wakes up at 6AM , have milk at 8AM , Meals at 9AM as breakfast and goes to farm at 2PM have meals ,and takes rest for sometime and goes to work ,and returns home and have dinner (meals /Roti )at 8PM and sleep .

Dietary habits : mixed diet (non allergic to any kind  of food ) 

Have water @ 2 litres /day 

Non alcoholic

Non smoker 

Environmental factors: from Battugudem, Nalgonda district (tropical region) 

Family History: No H/O Kidney diseases but H/O HTN,DM + 

7) 45YRS OLD MALE PATIENT, from Narketpally , Driver by Occupation, diagnosed with CKD ( 4YRS ago) 

H/O Chikungunya 4yrs ago (used medication ) 

On dialysis

Daily routine : 

Wakes up at 6AM ,have tea ,at around 7:30 have meals as breakfast and goes to work ,at 1PM have meals and goes to work and returns home at 5PM and have tea ,at around 8PM have dinner (meals ) and at 9PM goes to bed .

Dietary habits : mixed diet (non allergic to any food) 

Have water @ 4litres/day 

Occasional Alcoholic (Stopped since 4 years ) 

Non smoker 

Environmental factors: from Narketpally,Nalgonda district (tropical region )

Family History: No H/O kidney disease ,HTN ,DM 

8) A 40YRS OLD MALE PATIENT, from Veliminedu ,Sub Editor for Competitive Magazines (employee),Diagnosed with CKD (H/O NSAID abuse +nt ) 

K/C/O HTN (Diagnosed at age of 28yrs) and On medication

On dialysis through same AV fistula (working )since 5 years (as CKD diagnosed 5 yrs ago) 

Daily routine: 

Wakes up at 5:30 AM and have tea ,reads newspaper and at around 8AM have breakfast (upma/chapathi / dosa /idli) and goes to work and at 1PM have lunch (meals )and goes to work and returns home at 6PM and have tea and at 8PM have dinner (meals ) at 10PM -sleep 

Dietary habits: mixed diet (non allergic to any kind  of food ) 

Have water @ 3 litres /day 

Non alcoholic

Non smoker 

Environmental factors: from Veliminedu (tropical region) 

Family History: No H/O kidney diseases but H/O HTN (with  High recorded BP values ) in their family - Mother ,Father , Siblings (2 elder sisters and 1 twin sister ) ,Grand Father and Grand Mother 

H/O DM - Mother ,twin sister .