45 year old male with Chronic Kidney Disease

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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 45 year old male security guard by occupation came to OPD with chief complaints of 

Shortness of breath since 5 days 

Decreased urine output since 5 days 

Swelling in both lower limbs since 5 days 

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 5 days ago.Then he started having breathlessness,insidious in onset , gradually progressive in nature (Grade 2 - Grade 3) aggravated on walking and relieved on sitting.

No H/o orthopnea, paroxysmal nocturnal dyspnea. 

H/o decreased urine output since 5 days. associated with  increased in frequency in small amounts.

H/o swelling in both limbs below knee since 5 days which was insidious in onset and gradually progressed from ankle upto knee .It relieved on after dialysis.

No H/o nocturia.

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 

H/ o similar complaints in the past.He had similar complaints 5 years ago.He had bilateral pedal edema and decreased urine output so he came to our OPD and was diagnosed with renal failure after performing investigations.He is maintained on hemodialysis since then (twice weekly) 

K/c/o Diabetes and Hypertension (11 years ) .He is on medication.

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 is maintained on hemodialysis

Last 2 were on April 3 2023 and April 6 2023.

Hypertension: clinidipine 10 mg 

GENERAL EXAMINATION

Patient is coherent,conscious and cooperative .

Patient is well nourished.

Pallor present

No icterus, clubbing, cyanosis,lymphadenopathy,edema.(relieved after dialysis).

Vitals 

Temperature :99°F 

Blood pressure: 150/80 mm Hg

Pulse rate: 78 bpm

Respiratory Rate: 16 cpm

GRBS -161 mg/dl

SYSTEMIC EXAMINATION:

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.

Percussion: 

                                      Right                       Left 

Supraclavicular       Resonant             Resonant 

Infraclavicular        Resonant.             Resonant 

Mammary                Resonant              Resonant 

Axillary                     Resonant              Resonant 

Infra axillary          Resonant                Resonant 

Suprascapular        Resonant                Resonant 

Infrascapular          Resonant.               Resonant 

Interscapular          Resonant.               Resonant 

Auscultation:

                                    Right.                         Left 

Supraclavicular     NVBS.                        NVBS

Infraclavicular.       NVBS.                      NVBS 

Mammary                 NVBS.                     NVBS 

Axillary                     NVBS.                      NVBS

Infra axillary.          NVBS.                      NVBS 

Suprascapular         NVBS.                      NVBS 

Infrascapular          NVBS.                     NVBD

Interscapular           NVBS.                    NVBS

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 

Per abdomen:

Shape of abdomen: obese umbilicus-inverted 

No scars, sinuses, engorged veins.

No tenderness

No organomegaly.

Bowel sounds not heard 

Central nervous system:

Conscious

Normal speech.

No neurological deficit found.

PROVISIONAL DIAGNOSIS 

This is case of patient involving renal system probably chronic kidney disease secondary to Hypertension and Diabetes mellitus.

INVESTIGATIONS 

Serum iron -53 microgram/dl

Serum creatinine -15.2 mg/dl 

Blood urea -154mg/dL 

USG report