26 year old male with ckd

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Chief complaints : 

Pedal edema since 20 days 

Decreased urine output since 20 days 

Shortness of breath since 20 days 

History of present illness :


IN 2012 

• Patient had similar complaints for which he went to NIMS , there he was diagnosed with Hypertension and on  medications (? unknown )  and symptomatic treatment by which symptoms are subsided .

IN 2013 

• Patient had an episode of Hemoptysis and anuria for which he was taken to NIMS Hospitals , and USG showed Swelling of right kidney (? Pyelonephritis ? PCKD) for which patient underwent Rt Nephrectomy (no records available).

IN 2022 

• JULY 2022 

• Patient had decreased urine output followed by anuria and bilateral pedal oedema for which he was brought to our hospital , and he was started on Hemodialysis & was on MHD since then on day care basis.

K/c/o Hypertension since 10 years and on irregular medication. 
Not k/c/o DM 
No H/o Bronchial asthma
No H/o CVA , CAD 
No H/o Epilepsy 

PERSONAL HISTORY

Diet - Mixed 
Appetite - Decreased
Sleep - Inadequate 
Bladder - Decreased urine output 
Bowel movements - Regular 
No addictions 

FAMILY HISTORY

• Not significant 

SURGICAL HISTORY
 
• Patient underwent Right Nephrectomy 10 years ago .

GENERAL EXAMINATION

Patient is concious , coherent , co-operative 
Well oriented to Time place person 
Thin build and moderately nourished 
• Pallor - Present 
• Icterus - Absent 
• Clubbing - Absent 
• Koilonychia - Absent 
• Lymphedenopathy - Absent 
• Pedal oedema - present
• JVP - Normal 

VITALS

• Temperature - 99°F 
• Pulse rate - 105 bpm
• Respiratory rate - 20 cpm
• BP -  150/90 mmHg
• SPO2 - 98% on room air 
• GRBS - 146 mg/dl 




Provisional diagnosis: 

Chronic kidney disease..cause ?? 

Patient underwent hemodialysis for 1 session and followed by discharged at request due to personal reasons.

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