CASE OF CHRONIC KIDNEY DISEASE

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CASE:-

A 40yr old male came with chief complaints of 

•Pedal edema

•Decrease in urine output

•Facial puffiness

HISTORY OF PRESENTING ILLNESS:-

•Fever with increase in temperature and slight chills especially at night.

•Lower back pain

•I could observe slight hump at back of neck with pain.

•Cough with phlegm

HISTORY OF PAST ILLNESS:-

Not a known case of diabetes mellitus, hypertension,asthama.

TREATMENT HISTORY:-

No relavent history

PERSONAL HISTORY:-

 He is married and a farmer by proffesion.

Diet-nonveg

Bowel movements-regular

Micturition-decreased in output.no burning sensation

He is a non alcoholic and doesn't smoke.

#Normal daily routine of 40yr old male is he wakes up at 5:00a.m and finish his daily activities and have idly at 6:30a.m and eats his breakfast at 10:00a.m(rice and curry) goes out does farming in feilds and then comes back home at 6:00p.m and take his dinner(rice and curry).He occasionally goes to market for vegitables and things and chit chat with freinds and neighbors.He sleeps by 8-9:00pm.

FAMILY HISTORY:-

No relavent family history.

GENERAL EXAMINATION:-

Patient was consious, coherent and cooperative.

VITALS:-

Temperature-98.4F

Pulse rate-84/mm

Respiratory rate-24/mm

Blood pressure-130/70mmHg

Spo2-98% at room air

GRBS-136mg/do

Pallor-present

Ictrus-present

Clubbing-absent

Cyanosis-absent

Oedema-pesent in feet(pitting type)

Lymphadenopathy-absent

SYSTEMIC EXAMINATION:-

ABDOMEN:-

Scaphoid shaped abdomen

No tenderness

No palpable mass

No organomegaly

Bowel movements are heard-sluggish

Liver and spleen not palpable.

CVS:-

S1 and S2 heard

No thrills

No murmurs

RESPIRATORY SYSTEM:-

Dyspnoea absent

Wheeze absent

Position if trachea is center

Breath sounds central

INVESTIGATIONS:-

COMPLETE BLOOD PICTURE:-

Hepatitis B

Hepatitis C

Serum electrolytes:-

Serum creatinine:-

Blood urea:-

Haemogram:-

ULTRA SOUND OF ABDOMEN:-

PROVISIONAL DIAGNOSIS:

Chronic kidney disease on haemodialysis.