A 62 yr old male with pedal edema and fever

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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 62 year old male came to the OPD with chief complaints of

CHIEF COMPLAINTS:

Pedal edema since 1 month
Decreased urine output since 1 month
Fever since 3 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 3 years back then developed pedal edema, shortness of breath, fever, cough and was admitted in a private hospital hyd and diagnosed as renal failure.

In February 2022 patient came to kamineni Narketpalli with chief complaints of shortness of breath and decreased appetite and undergone dialysis under 3 sessions and was on conservative management.

In November 2022, patient came with similar complaints and undergone dialysis here

Now he developed pedal edema since 1 month which is pitting type and complained of fever since 3 days which is continuous ,high grade and associated with chills and rigor.

H/o nausea, vomiting, anorexia on 4th jan night.

Vomiting is non projectile, non bilious, non blood tinged contained food particles associated with nausea in 2-3 episodes.
H/o decreased urine output since 1month

No h/o burning micturition, pain abdomen.

H/o abscess over left medial and infra gluteal region 1 year back.

Came for dialysis ( no regular follow up)

Timeline of events:
PAST HISTORY:

K/C/O Diabetes  since 3 years
K/C/O Hypertension since 3 years and on medication for both

Patient had a history of knee injury 3 years back for which he undergone surgery.

N/K/C/O  CAD, epilepsy, asthma, Tuberculosis.
No history of any blood transfusions.

FAMILY HISTORY: No significant family history

PERSONAL HISTORY:

DIET: Mixed
APPETITE: Decreased
SLEEP: Adequate
BOWEL MOVEMENTS: Regular
BLADDER MOVEMENTS: Decreased urine output
ADDICTIONS: Drinks toddy occasionally

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative Well oriented to time, place and person
Moderately built and moderately nourished.


Pallor-absent
Icterus-absent
Cyanosis-absent
Clubbing-absent
Lymphadenopathy-absent
Pedal edema-present






VITALS:.                                                          .
Temp:Febrile(102°F)
Blood pressure:130/90mmHg
Pulse rate:82bpm
Respiratory rate:14cpm

SYSTEMIC EXAMINATION.                       

●Cardiovascular system:S1 S2 heard, no.     murmurs.
●Central nervous system:No focal neurological deficit.
●Respiratory system: Trachea-central.           
bilateral air entry +, normal vesicular breaths sounds heard
●Perabdomen examination:Soft, non tender and no organomegaly and bowel sounds heard.

PROVISIONAL DIAGNOSIS:
CKD secondary to DIABETIC NEPHROPATHY
With Anemia secondary to CKD
With pyrexia under evaluation ?UTI

INVESTIGATIONS:


◆Hemogram:
◆Complete urine examination:
◆Serum creatinine:

◆Blood sugar: Hypoglycemia(70mg/dl)
◆Blood urea:120mg/dl
◆Serum iron:
◆Serum electrolytes:
◆Liver function test:
◆ECG:
◆USG:
Impression:
1)Grade lll RPD changes noted in bilateral kidneys with complex renal cortical cysts.
2)Vesicle calculus 32mm is noted.

Doppler studies:
DISCUSSION:

Anemia secondary to CKD


●Chronic kidney disease, atherosclerotic plaque Characteristics on Carotid mri and cardiovascular outcomes
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7905597/

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