1601006182 LONG CASE

 1601006182  - GM LONG CASE 


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Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.


A 50yr old Male from Dhaamera came to the OPD with the chief complaints of swelling in face and both the legs since 3 months . 

History of present illness:
The patient was apparently asymptomatic 3 months ago then he developed 

Facial puffiness:
insidious in onset and gradually progressive. 

Pedal edema :
bilateral, insidious in onset and gradually progressive that started from the feet and progressed to the level of below the knees. Aggravated on fluid intake and not relieved on rest. 


Oliguria :
insidious in onset and gradual in progression since 1 year. 

No associated dribbling of urine, thin stream, forced micturition, suprapubic pain, dysuria. 

No history of fever, burning micturition. 
No History of hematuria.
No history of pruritus, easy bruisibilty.
No history of palpitations, dyspnoea on exertion. 

Past history :
No history of similar complaints in the past. 
Patient is a known case of hypertension since 3 years for which he took medication irregularly. ( now he is on regular medication since 3-4 months )
Not a known case of Diabetes mellitus, TB, Epilepsy, Asthma, Thyroid disorders. 

No significant surgical history. 

Family history : not significant 

Personal history :
Diet - Mixed
Increased salt intake - 8 g/day
Appetite - decreased
Sleep - Adequate
Bladder and bowel - Decreased urine output, Irregular bladder habits.
Addictions - Beedies 3/day since 10 years. 

Drug history : No known drug allergies 

General examination :
The patient is conscious, coherent, cooperative. 
Poorly built and poorly nourished. (BMI 15.2) 


Edema: pitting type of pedal edema upto knees ( grade 2)

Pallor- Present 


Icterus- absent
Cyanosis - Absent
Clubbing - Absent
Koilonychia - Absent
Lymphadenpathy - Absent 

Vitals :
Temperature - afebrile
Pulse - 82 /min
Blood pressure -150/80 mm hg
Respiratory rate - 16cpm
SpO2 - 98% 

Systemic examination :
Per abdomen:
Inspection :
- Shape of the abdomen: scaphoid

- All quadrants moving equally with respiration.
- Umbilicus: normal (inverted)
- No visible scars, sinuses.

Palpation :
- No tenderness.
- No organomegaly.
- THE KIDNEYS ARE NOT BIMANUALLY PALPABLE.

Percussion - tympanic note
Auscultation - Bowel sounds heard 

Respiratory system: 
Inspection:
- Trachea central
- Symmetrical chest expansion
Palpation:
- Bilaterally Symmetrical chest expansion
Percussion : Resonant note
Auscutation: Normal vesicular breath sounds heard
Bilateral air entry present 
No added sounds 

Cardiovascular system:
- S1 S2 heard
- No murmurs 


Central Nervous system :
- higher mental functions: intact
- Cranial nerves intact
- Sensory and motor system intact
- Cerebellar function  intact 

Provisional diagnosis:
Chronic kidney disease most probably due to uncontrolled hypertension. 

INVESTIGATIONS : 







Definitive diagnosis : 
Chronic kidney disease secondary to uncontrolled hypertension.






Differential diagnosis :
Hyperthyroidism

Treatment history :
Tab. Furosemide 40mg
Tab. Nifedipine SR 10mg 
Tab. Clonidine 100mcg
Tab. Sodium bicarbonate 500mg
Tab. Pantoprazole 40mg
Calcitriol capsules
Ferrous ascorbate and folic acid tablets 

He is on dialysis since 1 month. He has undergone 13 sessions of dialysis till date. 











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