A 60 year old male patient with CKD and sob

 This E blog also reflects my patient cantered 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.  

Case presentation :

A 60 year old male patient resident at suryapet with daily labour on occupation Came to opd with 

Chief complaints :

-bilateral pedal edema since 2 months 

- decrease urine output since 2 month 

- breathlessness since 10 days 

History of presenting illness :

Patient was apparently asymptomatic 2 months back then he developed bilateral pedal edema , insidious in onset , gradually progressive , which is pitting type and extended Upto knee. Aggravated on walking and physical activity , relieved after dialysis. 

Then later he developed decrease in urine output which is more in frequency but less in quantity (10-15 ml ) h/o nocturia ( 4 times during night ) 

He recently developed shortness of breath 10 days back which is insidious in onset , gradually progressive , initiated with grade 1 then progressed to grade 4 ( even on rest ) aggravated on walking , physical activity and relieved on rest 

No h/o orthopnoea , chest pain , pnd 

No h/o fever , vomitings , cough 

No h/o palpitations , sweating 

No h/o headache , sleep disturbances 

No h/o heamturia 

Past history :

No similar complaints in the past 

K/c/o diabetes since 6 years (Glimi-m1)

K/c/o hypertension since 3 years ( t - amlokind - 80 )

No h/o epilepsy , tuberculosis , asthma 

He underwent fistulectomy 5 years ago 

Personal history :

Mixed diet 

Adequate sleep 

Regular bowel movements 

Decrease urine output 

He stopped alcohol 1 year ago 

No smoking 

No allergies 

Family history :

Not significant 

General examination:

Patient was coherent , conscious , cooperate 

Moderately built , moderately nourished 

No signs of pallor , icterus , clubbing , kolinychia , lymphadenopathy 

Vitals :

Temperature - afebrile 

Heart rate - 80 bpm 

Bp - 120/80 mmhg 

Rr - 16 cpm 

Systemic examination :

Respiratory 

Inspection

Trachea appears to Be central 

Shape of chest appears to elliptical 

Chest movements appears to Be equal on both sides 

No drooping of shoulder , spine deformities 

No scars , sinuses , swellings , engorged veins 

No hallowing 

No crowding of ribs 

Apical impulse is seen 

Palpation :

All inspection findings is confirmed 

Trachea is midline 

No local rise of temperature 

No tenderness 

Apical impulse in felt 

Bilateral chest movements are equal 

No swellings , mass are felt 

Vocal fermitus - normal 

Percussion :

Bilateral resonant 

Auscultation :

Bilateral vesicular breath sounds are heard 

Central nervous system -

No focal deficits 

Per abdomen :

Non tender , soft 

Cardiovascular system :

S1, s2 heard ; no murmurs 





Provisional diagnosis :
 Chronic renal failure with MHD

Investigations













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