Case history 1

 August 16,2021

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August 9, 2021

A 60 yr old male patient resident of Suryapet presented to opd with chief complaints of shortness of breath ,swelling in the legs and decreased urine output since 3 months.

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 3 months back then there was shortness of breath since yesterday.

There is pedal edema since few days.

There is decrease in urine output since few days.

Also there is associated back pain.

There is burning sensation during micturition.

Patient also has weakness.

PAST HISTORY

Patient is known hypertensive and diabetic since 16 years and he is taking medication for both.

Once 8 years back with problem of pedal edema he went to hospital and doctors diagnosed as kidney failure and patient took medication.On medication problem of pedal edema had reduced but it was recurring.

PERSONAL HISTORY

Patient has normal eating habit.8 yrs back he used to eat mixed diet but now he is vegetarian.

Appetite is normal.

He has habit of alcohal.

Bowel  movements are regular.

Decreased urine output.

Inadequate sleep.

FAMILY HISTORY

No significant history in his family.

GENERAL EXAMINATION

Patient is conscious,coherent, cooperative lying in supine position on the bed in well lit room.

Moderately built.

Patient is pallor.

Bipedal edema is present.

No cyanosis.

No jaundice.

No clubbing of fingers.

No lymphadenopathy.

VITALS  

Temperature- Afebrile 

Pulse rate -100/ min 

Respiratory rate - 22/ min 

Blood pressure - 140/90 mm/ hg 

Spo2 -98%

Grbs -144 mg%

SYSTEMIC EXAMINATION

CVS- S1 S2 heard.

Respiratory system - Bae present ,no abnormalities

CNS- No focal neurological deficits 

PROVISIONAL DIAGNOSIS

Chronic kidney disease on MHD 

INVESTIGATION:

COMPLETE BLOOD PICTURE

Hemoglobin - 6.8 gm/dl 

Total count- 4800 cells/cumm 

Neutrophils- 60% 

Lymphocytes-30% 

Eosinophils-01% 

Monocytes-09% 

Basophils-0% 

Platelet count-1lakh/cumm 

Smear-normocytic, normochromic anemia with thrombocytopenia 

Serum creatinine-6.8mg/dl 

Blood urea-101mg/dl 

Serum electrolytes- 

Sodium-128mEq/L 

Potassium-3.3mEq/L 

Chloride- 90mEq/L 

Serum iron- 73.9ug/dl 

Anti HCV antibodies -Rapid test- 

Nonreactive 

Method -immuno chromatography

Anti HIV 1/2 Rapid test- 

Non reactive 

Method - immuno chromatography 

Investigation:

Questions- 

1. Is diabetes the main cause for CKD in this patient?If so, he had diabetes since 16years why might the problem of CKD arised since 8 years.

2. If he would have started dialysis before 8 years when he knew it has CKD, would the problem solve or it would re occur again?