66 M k/c/o CKD with b/l pedal edema and ascites

 A 66 years old male resident of pothunuru 

A farmer by occupation since the past 40 years 

CHIEF COMPLAINTS - 

1. pedal oedema since 2 months 
2. dyspnea since 2 years 

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 2 years ago , when he developed fever which was intermittent in nature , associated with generalised weakness in view of this he was taken to miryalguda hospital , where he underwent tests and ultrasound , where he was found to have chronic kidney disease of left kidney , was prescribed medications for the same .

One year later patient developed severe pain in the loin region radiating to the front laterally on either sides 

The pain was so extreme and patient says “had it continued any further than it did  , I’d be dead “ 

patient was taken to max cure Hyderabad where he whole body examination, and found to have b/l CKD of grade ll. 

He’s stay and diagnostics costed him 1 lakh here 

he later got discharged and continued to take medications for pain , even though the level of pain reduced , but he continued to have low grade pain 

3 months ago , he visited Nalgonda hospital in view of his pain in loin region , patient underwent tests and was advised to get dialysis done , twice weekly 

Which patient didn’t not agree to , he felt the distance to be a constraint, hospital is 109 kms from his hometown and visiting hospital every week twice did not seem easy 

One month ago , he visited miryalguda hospital , due to similar pains in the loin region and pedal oedema in b/l lower limbs extending upto to the ankles 

he was given medication for his pain 

And pain completely subsided 

Pedal oedema didn’t resolve 

was brought to us , through camp being held in his village .

PAST HISTORY 

patient is a known case of DM since 9 years 

K/c/o Htn since 3 years 

MEDICATION HISTORY 

Glimeperide since 9 years 

Antihypertensive medication

AMLONG 5 mg since 3 years 

PERSONAL HISTORY 

• diet - mixed 
• Appetite - normal 

Daily routine 

Breakfast by 8:00am 

Leaves to work by 9:00am 

Patient owns a farm land 

Earlier patient used to do all the required work 

From preparing the land by ploughing and transplanting the seedling , to maintained and harvesting 

Heavy weighting work of lifting sacks of rice and etc 

since 2 years , his dyspnea and old age has restricted his work mainly to looking after the field and sometimes harvesting if he feels energised enough to do work .

Endurance has significantly reduced .

• Sleep - adequate 

• Addictions- patient used to consume alcohol , stopped drinking whiskey 10 years ago 

Used to consume alcohol frequently, if he had enough money , even on daily basis a few weeks 

smoked bidis- 1 pack per day ,20 bidis per day (stopped 10 years ago) 

Bowel and bladder - regular 

General examination 

Patient is conscious , coherent and co operative well oriented to time place and person 

Vitals 

TEMP -98.7F

BP -130/70mmHg

HR -72bpm

RR -chest movement is not significantly visible as that of a normal person .

pedal edema on b/l feet upto ankles 

investigations :

HB-9.7g/dl 

PVC-29

TLC-6500cells/cumm

RBC-3.25million

Platelets -1.04 lakhs/cumm

RBS-111g/dl

UREA-91g/dl

S.CREATITINE- 3.7

S.Na-139

S.K-4.1

S.Cl-101

T.bilirubin -0.77

Direct bilirubin-0.20

SGOT-13

SGPT-18

ALP-133

A/G-1.38

Albumin -4.1

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 are not visible to naked eye 

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 

TD-38 

AP-30

AP/TD-0.7 

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, 

shifting dullness present 

Bowel sounds present

CENTRAL NERVOUS SYSTEM:

HMF - Intact                                   R.        L.

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

                                                   LL  5/5      5/5

TONE - Normal.

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

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

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

CRANIAL NERVES - Normal.

Provisional DIAGNOSIS 

disease involving the renal system , chronic kidney disease secondary to diabetic nephropathy with assosiated symptoms of  heart failure like ascites , dyspnea .