65 year old male with CKD

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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.

A 65 year old male plumber by occupation resident of suryapet came to OPD with chief complaints of Breathlessness since 6 months .Swelling in both limbs (below knee) since 5 months .Decreased urine output since 5 months.

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 6 months ago ,then he developed breathlessness which was insidious in onset, gradually progressive in nature .It initially started while going up stairs and later he hast to take rest after walking for a while. (grade 2) .it aggrevated on walking. It relieved on sitting.  

No h/o orthopnea, paroxysmal nocturnal dyspnea.

H/o swelling in both limbs (below knee) since 5 months which was insidious in onset and gradually progressive in nature .It was pitting type.It aggrevated while working It relieved after dialysis.

H/o decreased urinary output since 5 months.Increased frequency (10 -15 ) times in a day in small amounts.

H/o nocturia (atleast 4 times in a night)

No H/o nausea, vomiting, loose stools, constipation.

No H/o fever, cough ,cold .

No H/o palpitations, sweating .

No H/O chest pain.

No H/o abdominal distension, abdominal pain.

No H/o hematuria.

No h/o headache,sleep disturbances.

PAST HISTORY :

K/c/o Diabetes since 6 years 

K/c/o Hypertension since 3 years.

Not a k/c/o Tuberculosis, Epilepsy, Asthma

PERSONAL HISTORY

Mixed diet 

Normal Appetite

Adequate sleep

Regular bowel movements.

Decreased urine output 

No allergies

Occasional alcoholic .

No smoking .

FAMILY HISTORY

Not relevant

TREATMENT HISTORY

He underwent dialysis for 3 times past 1 week .

1st dialysis on 29 -3-2023

2nd dialysis on 31 -3-2023 

3rd dialysis on 3 -4-2023 .

2 units of blood transfusion due to severe anemia  

GENERAL EXAMINATION

Patient is coherent,conscious and cooperative .

Patient is well nourished.

Pallor present 

No icterus, clubbing, cyanosis,lymphadenopathy,edema.

Vitals 

Temperature :97°F 

Blood pressure: 150 /90 mm Hg

Pulse rate: 78 bpm

Respiratory Rate: 16cpm

GRBS -136mg/dL

SYSTEMIC EXAMINATION :

Per abdomen: 

Inspection -

Shape of abdomen : scaphoid

Umbilicus : inverted 

Movements of abdomen wall with respiration 

No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites 

On palpation -

No local rise of temperature 

Inspectors findings are confirmed 

Soft and non tender

No palpable mass 

Liver and spleen not palpable 

On percussion -

Resonance note heard

On auscultation -

Bowel sounds heard

Respiratory system:

Inspection: 

No structural abnormalities in nose, no obstruction in nasal airway .

Oral cavity - no crooked teeth

Pigmented patches present on tongue .

No ulcers in mouth. 

Trachea appears to be central.

Bilateral symmetrical.Elliptical in shape.

Symmetrical expansion on both sides.

No scars ,sinuses,engorged veins.

Palpation:

No local rise of temperature

No tenderness.

Trachea is central.

Apex beat present in medical to mid clavicular line in 5th intercostal space.

Chest expansion equal on both sides.

Tactile vocal fremitus present on both sides.

Auscultation:

Cardiovascular system:

Inspection- 

No raised JVP

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse at 5th intercostal space

Palpation-

Apex beat is felt in the fifth intercostal space, 1 cm medial to the midclavicular line

Right and left borders of the heart are percussed 

Auscultation-

S1 and S2 heard, no added thrills and murmurs are heard 

Central nervous system:

Conscious

Normal speech.

No neurological deficit found.

PROVISIONAL DIAGNOSIS

Chronic Kidney Disease maintenance in hemodialysis.

INVESTIGATIONS 

GRBS - 136 mg/dl 

Blood group -B+ve 

Serum chloride -100 mmol/L 

Potassium -4.0 mmol/L 

Sodium -136 mmol/L 

Serum creatinine - 8.5 mg/dl  

Blood urea - 169 mg/dl 

Right kidney -decreased size and increased echotexture 

Left kidney - Normal size and increased echotexture.