65 years old came with chief complaints of pedal edama and SOB

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65 years old male came to old with chief complaints of decreased urine output since 6 months

Bilateral swelling of legs since 6 months

Shorthness of breath since 6 months


HOPI

Patient was apparently asymptomatic 6 months back then he had 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 nocturia

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

H/O dyspnea 6 months ago which was insidious in onset gradually progressed from grade1 to grade 2 according to MMRC 

Aggrevated on walking relived by rest

No H/O orthopnea ,PND

No H/0 chestpain 

No h/o Fever,nausea,vomitings

No h/o hematuria 


PAST HISTORY:

K/C/O DM since 6 years, HTN since 3 yrs

No  H/O epilepsy, CAD,CVA, TB, asthma

PERSONAL HISTORY:

Mixed diet

Adequate sleep

Regular bowel and bladder movements

No smoking and no allergies

Stopped alcohol 1 yr ago 180ml / day

He had fistulectomy

FAMILY HISTORY:

not significant

GENERAL EXAMINATION:

Patient is c/c/c


No signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.


Temp-Afebrile 


BP- 130/80mmhg


PR - 80bpm


RR - 18cpm


Systemic examination 


R/S - inspection:

Trachea appears to be normal - Central 


shape of chest - elliptical 


Movements of chest appear to be bilaterally equal


No scars , sinuses present.

No drooping of shoulder

No engorged veins , swellings seen

No hallowing seen

No crowding of ribs


Palpation:

All inspectory findings are confirmed

No rise of temperature

No tenderness 

Trachea is in midline

B/L chest movements are equal

No swelling and palpable masses are felt

vocal fremitus are normal

Apical impulse - felt


PERCUSSION.                        RT.            LT

SUPRA CLAVICULAR       resonant.  resonant

INFRA CLAVICULAR.       resonant.  resonant

MAMMARY.                       resonant.  resonant

INFRA MAMMARY.           resonant.  resonant

AXILLARY.                         resonant   resonant

INFRA AXILLARY.             resonant   resonant

SUPRA SCAPULAR.        resonant   resonant

INFRA SCAPULAR.         resonant   resonant

INTER SCAPULAR.          resonant   resonant



Auscultation:


Vesicular breath sounds 


SUPRA CLAVICULAR      NVBS.          NVBS

INFRA CLAVICULAR.      NVBS.          NVBS

MAMMARY.                      NVBS.          NVBS

INFRA MAMMARY.           NVBS.          NVBS

AXILLARY.                         NVBS.          NVBS

INFRA AXILLARY.             NVBS.          NVBS

SUPRA SCAPULAR.        NVBS.          NVBS

INFRA SCAPULAR.         NVBS.          NVBS

INTER SCAPULAR.          NVBS.          NVBS





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



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

Percussion -

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 








Provisional diagnosis

Chronic kidney disease 


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