1601006191 SHORT CASE

 1601006191

This is the online elog book , to discuss the patients health condition with the signed informed consent.

A 45year old male , resident of suryapet farmer by occupation came to hospital with

Chief complaints of

Shortness of breath , Decreased urine output and pedal edema since 2 years.

History of presenting illness

Patient was apparently asymptomatic 2 years ago, then he developed shortness of breath , which was insidious in onset and gradually progressed from grade 2 to grade 4.

Then he developed bilateral pedal oedema , pitting type, insidious in onset ,gradually progressive and present throughout the day and increased on walking. No relieving factors.

H/o decreased urine output since 2 years and associated with pain in the loin not radiating.

No history of burning micturition and  chest pain , fever.

Past History

K/c/o hypertension since 12 years

Not a k/c/o Diabetes mellitus, TB , EPILEPSY, asthma.

Family history - Not significant

Personal history

Diet : Mixed

Appetite : Normal

Sleep: Adequate

Bowel: Regular and bladder frequency is decreased 

No known drug allergies

 General physical examination:

Patient is conscious, coherent , co-operative, moderately built and moderately nourished.

Pallor: present

Icterus : absent

Cyanosis: absent

Clubbing: absent

Koilonychia: absent

Lymphadenopathy: absent

Edema : bilateral pedal oedema present






Vitals:

Patient is Afebrile

Pulse : 90 beats/min

Respiratory rate : 22 cycles / min

BP : 140/90 mmHg

Per Abdomen: 

Palpation:

Distended abdomen



Umbilicus -Central in position and slit like

Flanks are full

Palpation : No local rise in temperature , No tenderness 

No organomegaly 

Percussion:

Dullness in the Flanks with tympanic note in the central.

Auscultation: bowel sounds are heard.

Respiratory system examination: 

Normal Vesicular Breath sounds heard , No added sounds

CVS examination:

S1 and S2 heard , No murmurs heard

CNS examination: 

Higher mental functions-normal 

Cranial nerves- intact

Sensory system- normal

Motor system- normal 

Investigations:

Haemogram:

Blood group o+









RFT: 
urea, creatinine, uric acid and phosporus  levels are elevated

LFT:


Provisional diagnosis: Chronic kidney disease

Treatment: 

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