SHORT CASE 2

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60 year old female , ex farmer presented to casuality with c/o

* Pedal edema since 2 months

*Decreased urine output since 2 months

HISTORY OF PRESENTING ILLNESS

Patient is ex farmer by occupation , was apparently asymptomatic 2 months ago . 

Patient was apparently asymptomatic 5 years back, then she met with RTA, Where she fell on the divider and sustained injury on right side of head.

CT showed bleed and was operated as per patient.? Craniotomy 

-Intially she noticed b/l swelling of lower limbs , gradual onset and progressive . Pitting type and extending upto knees .

Not associated with shortness of breath 

Associated with decreased urine output 

Not associated with orthopnea and PND 

No h/o chest pain , palpitations 

In view of pedal edema , patient visited local hospital and was told ,She had a stone in one of her kidneys and both her kidneys failed .

She used NSAIDS for over 3 months I/v/o low backache.

She was advised maintenance hemodialysis,but patient denied and was discharged on medications .

Later, pedal edema subsided after using medications .

She continued taking medications , but noticed loss of appetite, fatigue and generalized weakness .

No h/o pus in urine , burning micturition , frothy urine .

As she had generalized fatigue ,loss of appetite and elevated urea and s. creatinine ,she visited our hospital and was initiated on hemodialysis by placing central venous catheter in right internal jugular vein .

Patient had 4 sessions of hemodialysis .

She went to Hyderabad and got A-V fistula on his left hand .

C/o Low back ache and body pains .

C/O abdominal distension since 5 days , sudden onset and progressed gradually . Associated with increased sob on lying down and abdominal tightness.

Pedal edema is mild extending upto ankle joint.

No h/o yellowish discoloration of eyes . No h/o binge alcohol intake .

PAST HISTORY 

 K/c/o HTN since 10 years and is not on regular medication .

NOT a k/c/o DM, TB , ASTHMA,CAD , EPILEPSY,CVA .

No surgical history and past Medical history

PERSONAL HISTORY

Regular bowel and bladder movements 

Adequate sleep 

Loss of appetite present 

Mixed diet 

FAMILY HISTORY - Not significant 

Addictions - Toddy drinker occasionally -3 times /week . 90 ml 

Non -Smoker 

GENERAL EXAMINATION: 

Pt C/C/C

No pallor, icterus , clubbing, cyanosis,koilonychia , lymphadenopathy 

B/L pedal edema - pitting type present. extending upto ankle .

Jvp - couldn't be assessed due to central line .

Skin - Dry ,scaly , itching present .

Eyes - Grade 2 HTN retinopathy changes noted on fundoscopy .

Vitals : 

Bp - 140/90 mmhg - Right arm supine posture

Pulse - 130 bpm ,regular ,normal volume, condition of vessel wall - normal, no radio-radial or radio-femoral delay.

Resp rate - 26/ min

Spo2 - 97% o

Grbs - 110 mg/dl 

Temp -99 F 

SYSTEMIC EXAMINATION : 

GIT EXAMINATION : 

INSPECTION : 

Shape of abdomen - Distended-uniform 

Flanks – Full

Umbilicus – Everted 

Skin – Stretched, shiny 

No scars, sinuses, striae, nodules , discoloration.

Dilated veins – absent 

Movements of the abdominal wall - All quadrants equally moving with respiration .

Abdomino - Thoracic type of breathing

NO visible intestinal peristalsis

Hernial Orifices normal 

Cough impulse - Negative 

PALPATION 

No local rise of temperature 

No tenderness 

Hernial Orifices - normal

Murphy’s Punch/Renal angle tenderness - no tenderness

PERCUSSION:

Fluid Thrill - Absent 

Shifting dullness - Absent

AUSCULTATION:

Bowel sounds – Present 

Aortic, Renal Bruit - Absent 

CARDIOVASCULAR EXAMINATION : 

INSPECTION:

Chest wall shape - Ellipsoid and b/l symmetrical

No Precordial bulge, Pectus carinatum/excavatum

No Kyphoscoliosis

No Dilated veins, scars, sinuses

Apical impulse - Visible in left 5 ICS 1 cm lateral to MCL .

Pulsations – epigastric, parasternal - absent 

PALPATION:

Apical impulse – Tapping type , felt in left 5 ICS 1 cm lateral to 

          No Thrills and palpable heart sounds .

Auscultation : 

S1 S2 heard in Aortic , pulmonary,tricuspid and mitral areas .

No added sounds 

No murmurs 

Respiratory system -B/L NVBS  

CNS - NO abnormality detected

PROVISIONAL DIAGNOSIS 

Chronic kidney disease secondary to NSAID abuse

INVESTIGATIONS 

FINAL DIAGNOSIS 

Chronic Kidney Disease with egfr 25 mL/ min square.