55 year old k/c/o chronic kidney disease with pedal edema since 10 days

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CHEIF COMPLAINTS 

The patient is a 55-year-old resident of Kodada who works as a labourer

Came for regular dialysis session 

HISTORY OF PRESENTING ILLNESS 

He presented with multiple complaints, including a history of alcohol use for 10 years until 2006 when he was between 25 to 40 years old. Stopped alcohol consumption upon taking up the ayyappaswamy ritual completed the pilgrimage to Ayyappa Swamy approximately 50 times, between the ages of 25 to 30 when he worked as a toddy tapper. During these days he experienced severe lower limb pains upto the level of ankles which were insidious in onset and gradually porigeessive in nature associated with pedal edema ,pedal edema that worsens upon walking but is relieved by taking NSAIDs.,for which patient used to take NSAIDS prescribed by rmp in a regular basis (weekly twice on average ),he also received injection at the RMP clinic for the same on several occasions ,

His kidney failure was incidentally found and He has been experiencing high blood sugar for the last 4 years which was incidentally found out through investigations done in order to treat his lower limb pains 

shortness of breath for the past days , which improved with RMP medication. He also reported feeling giddy on regular basis (one episode today in the morning ) and having decreased urine output associated with urinary hesitancy for a year


PERSONAL HISTORY 

The patient has two sons, elder son is married ,one married daughter who is pursuing PhD in pharmacy in hyd , and younger son who is 30 years .


SURGICAL HISTORY 

He has a surgical history of hydrocele which he developed on lifting heavy jute sacks along with hydrocele he had also developed umbilical hernia (not treated ,asymptomatic ever since )and cataract surgery in 2015. 

Additionally, he has undergone 10 dialysis sessions in August.


PAST HISTORY 

K/c/o type 2 DM since 4 years 

History of hydrocele and umbilical hernia 10 years back 

FAMILY HISTORY 

No similar complaints in family 

Family was a diabetic 

75 years 

Wife -diabetic 

Mother is hypertensive 

6 brothers -4 of them are diabetic 

TREATMENT HISTORY 

calcitriol tablets 

Oha’s since 4 years 



GENERAL EXAMINATION 

PALLOR -present in lower palpebral conjunctiva 




ICTERUS -absent 

CYANOSIS  -absent

CLUBBING  -absent

LYMPHADENOPATHY  -absent

PEDAL EDEMA -present upto ankles ,pitting  type 




VITALS 


- Blood pressure: 140/90 mmHg .

- Heart rate: 60-100 beats per minute.

- Respiratory rate: Around 20-30 breaths per minute.

- Temperature: Roughly 36.5-37.5 degrees Celsius

HEAD TO TOE EXAMINATION


PER ABDOMEN EXAMINATION 



CVS EXAMINATION

INSPECTION 


Chest is bilaterally symmetrical 
No precordial bulge
Apex impulse visible in 6th intercostal space at midclavicular line 
No visible pulsations, sinus, scars, or dilated veins.

Palpation: 
All inspection findings are confirmed 
Apex impulse - felt in 6th intercostal space at midclavicular line 
No parasternal heave 
No palpable thrills

Auscultation: 
Mitral area - S1 and S2 heard, no murmurs
Aortic area - S1 and S2 heard ,no murmurs
Pulmonary area - S1 and S2 heard ,no murmurs
Tricuspid area - S1 and S2 heard ,no murmurs


RESPIRATORY SYSTEM:

Inspection:

Chest is elliptical & bilaterally symmetrical

Trachea appears to be central

Movements appear to be equal on both sides

No visible pulsations, sinus, scars, or dilated veins.

Palpation:

All inspection findings are confirmed
Trachea central
Movements equal on both sides
Transverse diameter > Antero-posterior diameter 
Apex beat felt in 6th intercostal space at midclavicular line 
Tactile vocal fremitus: equal on both sides in all areas

Percussion:

Resonant note heard in all areas

Auscultation:

Bilateral air entry present

Normal vesicular breath sounds were heard

Fine crepts heard bilaterally in mammary, infra mammary, axillary, infra axillary & infra scapular areas


PER ABDOMEN:

Obese abdomen

 Midline everted umbilicus with umbilical hernia 

No visible pulsations/engorged veins/sinuses

Soft, non-tender, no organomegaly, no free fluid

Bowel sounds present


CENTRAL NERVOUS SYSTEM:

HMF - Intact                                   R.        L.

MOTOR SYSTEM: Power:      UL 4/5      4/5

                                                   LL  4/5      4/5

TONE - Normal.

REFLEXES - B.    T.    S.     K.    A.   P.

               R.     +2  +2.  +1.   +2.   --.  Flexion.

               L.     +2. +2.  +2.   +2.   --.  Flexion.

CRANIAL NERVES - Normal.


INVESTIGATIONS 








PROVISIONAL DIAGNOSIS 

Chronic kidney disease probably secondary to diabetes 


TREATMENT 

Maintance hemodialysis 

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