54M farmer with decreased urine output and pedal edema

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient' problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

A 54 years old male, farmer by occupation resident of kattangur presented with complaints of : 

Decreased urine output since 3 days, 

B/L lower limb swelling since 3 days.

Patient was apparently alright 10 years back then he had decreased urine output associated with pedal edema, And loss of appetite, then he went to local RMP and treated symptomatically for 1 month. Inspite of which his symptoms recurred, so he went to a private hospital in Nalgonda there he was told to have renal failure and referred to Kim's NKP and he was evaluated and  conservative treatment was done for 1 week and discharged. 

6 years he was on conservative treatment for Renal failure.

In 2018 on occasion of sankranthi festival ( January) patient and family had rituals and family lunch which majorly comprised of Mutton and Chicken following which he developed loose stools 4-5 episodes, watery consistency, for 2-3 days. associated with nausea and abdominal discomfort. Then he was admitted in outside hospital in Hyderabad and told that his urea and creatinine is high and advised for dialysis and also diagnosed with Hypertension.

Patient was started on Hemodialysis in January 2018 1 session of dialysis was done and they left that hospital and joined KIMS NKP for further sessions dialysis.

Since then patient stopped his daily routine farming due to weakness and loss of appetite.

Patient was dialysed for 1 year and changed 3 central lines at different sites.

Patient undergone AV fistula surgery in 2019 since then undergoing maintainance hemodialysis through RT hand AV fistula weekly twice.

Now patient came for routine maintainance hemodialysis with complaints of pedal edema and decreased urine output.

Known case of CRF since 10 yrs

Known case of HTN since 4 yrs.

Personal history :

Appetite : decreased 

Diet : mixed 

Sleep : adequate 

Bladder : decreased urine output

Bowel movements: regular 

Addictions :absent 

 

General examination:

Pallor: present 

Icterus: absent 

Cyanosis : absent 

Clubbing : absent 

Lymphadenopathy : absent 

Edema : present B/L pitting type of pedal edema.

Vitals:

 Temperature: afebrile 

 Pulse: 89 bpm

 Blood pressure:130/80 mm of hg

 Respiratory rate : 20 bpm

SpO2 : 98 on RA

GRBS : 138 MG/DL

Systemic examination:

Cardiovascular system  

JVP - Not raised 

Visible pulsations: absent 

Apical impulse : left 5th intercostal space in midclavicular line.

Thrills -absent 

S1, S2 - heart sounds heard 

Pericardial rub - absent

Respiratory system:

Patient examined in sitting position

Inspection:-

oral cavity- Normal ,nose- normal ,pharynx-normal 

Shape of chest - normal

Chest movements : bilaterally symmetrical 

Trachea is central in position.

Palpation:-

All inspiratory findings are confirmed

Trachea central in position

Apical impulse in left 5th ICS, 

Chest movements bilaterally symmetrical 

AUSCULTATION 

B/L IAA crepts present.

Abdomen examination:

INSPECTION

Shape : distended 

Umbilicus:normal 

Movements :normal

Visible pulsations :absent

Skin or surface of the abdomen : normal 

PERCUSSION- tympanic

AUSCULTATION :bowel sounds heard

USG : 

Labs : 

Diagnosis: 

CHRONIC KIDNEY DISEASE ON MAINTAINANCE HEMODIALYSIS WITH HYPERTENSION.

Treatment : 

1. Hemodialysis initiated on JAN 2018

2. Salt and fluid restrictions 

3. T. Lasix 4o mg BD

4. T. Arkamine 0.1mg BD

5. T NODOSIS 500mg BD

6. T. Orofer-XT OD

7. T. Shelcal 500mg PO OD

8. T. Nicardia 20mg BD

9. T. Met-XL 25 mg OD