CKD General Medicine Long Case

January 20 , 2023

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Date of admission: 19-01-2023

CHIEF COMPLAINTS

A 50 yrs old male patient  came to opd with the chief Complaint of pedal edema since 1 month , fever since 4 days.

HISTORY OF PRESENT ILLNESS 

Patient was apparantly asymptomatic 6months months back and  then he  experienced fever , chills , rigor with vomitings. He was admitted in local hospital and was found to have raised creatinine levels (5.1)  ( diagnosed as renal failure). He was under observation for 10days and treated . He was on medication for 5months. Later one month back he developed pedal edema Later 4 days back he developed fever which is intermittent type no diurnal variation , not associated with cough and cold , burning micturition loose stools vomiting , associated with chills  and rigors subsided on taking medication.

HISTORY OF PAST ILLNESS 

H/O generalized leg pain since 15 years back. He took pain killers ( NSAIDS)( dolo ) for 5-6 years.

H/O left hip replacement 10 years back

Know case of hypertension since 5 years ( atenolol)

No h/o generalized itching , 

No h/o pruritis, 

No h/o dribbling or increase frequency of urination , 

No h/o urgency to urinate

No h/o periorbital edema.

No H/o chest pain, chest tightness.

No h/o epilepsy, CAD, asthma

PERSONAL HISTORY 

Patient is shop keeper by occupation he used to wake up 5 am in the morning and performs his daily activities normally ( brushing , bathing , timely taking food ,adequate sleeping). He used to not perform well during fever episodes.

Appetite : normal 

Diet: vegetarian 

Sleep :adequate 

Bowel and bladder movements:regular 

Alcohol: stopped since 15 years 

Family history 

 No relevant family history 

GENERAL EXAMINATION 

Patient is concious coherent cooperative 

Pallor , edema of feet present

No icterus cyanosis clubbing lymphadenopathy

Vitals: 

Temp: 102 f 

Respiratory rate: 18cycles/min

Pulse: 98beats/min

Blood pressure: 110/80mmHg

Systemic examination ;

By taking the consent of the patient I have examined him in a well lit room

CVS Examination

Thrills: No

Cardiac sounds: S1, S2 heard 

Inspection:-

Chest - bilaterally symmetrical 

Scars sinuses engorged veins are not seen on  chest.

Palpation:- 

Murmurs - absent

Thrills - absent 

Percussion

Heart borders are appreciated 

Auscultation:-

S1 S2 heard 

Cardiac rate - 98 beats per minute 

No cardiac murmurs heard

Respiratory system 

Position of trachea: Central

Auscultation

Normal vesicular breath sounds heard 

Dysponea: absent 

Percussion

No dull note felt 

 Inspection 

Chest -Bilaterally symmetrical 

Shape - elliptical 

Respiratory movements are normal

Scars sinuses dilated veins are not seen.

No crowding of ribs. Visible pulsation are not found. Accessory muscles are not used.

Palpation :-

All inspectory findings are confirmed

Trachea -central 

Chest movements-symmetrical

Abdominal examination 

Inspection

Shape of the abdomen- scaphoid 

Flanks are normal 

Umbilicus- vertical oval 

Sinuses  engorged veins and scars are not seen.

Palpation:

Temperature : no local rise in temperature 

Tenderness  : not tender 

Mass : no palpable mass

Organomegaly not present 

Percussion:

Thirll : fliud thrill not felt 

Shifting dullness not present 

Auscultation:

Bowel sounds are heard.

CENTRAL NERVOUS SYSTEM 

Patient is conscious, coherent, cooperatively well oriented to time and place.

Normal speech

Intelligence : good

No hallucinations

DIALYSIS data

Patient underwent 4 sessions of dialysis 

PROVISIONAL DIAGNOSIS 

CHRONIC KIDNEY DISEASE on MHD 

Hypertension since 5 years 

Clinical investigation : 

Investigations 

USG

Complete urine examination 

Renal function test 

Hemogram 

Serum Electrolyte 

Random blood sugar 

ECG 

2D echo findings 

Fever chart

 

Treatment 

T met xl 500 mg po od

T orofer XT po od

T lasix 40mg po bd

T Shelcal po od

Cap bio d3 po od

T nodosis 500mg po bd

T nicardia 10mg po bd

Inj epo 4000 iu sc weekly once

Tab sevelamer 400mg  bd