62 yr old male CKD secondary to diabetic nephropathy

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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

Chief complaints : 

Pedal edema since 1 month 

Decreased urine output

Fever since 2 days assosiated with chills and rigor

History of present 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/march 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 2 days which is continuous ,high grade and associated with chills and rigor.

H/o nausea, vomiting, anorexia 04jan night.

Vomiting is non projectile, non bilious, non blood tinged contained food particles associated with nausea in 2-3 episodes.

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)

Past history :

Patient was diagnosed as diabetic 3yrs back and hypertensive six years back

Patient is a known case of CKD

 No history of TB Epilepsy

 FAMILY HISTORY 

no significant family history

PERSONAL HISTORY 

Diet : mixed 

Appetite: decreased 

Bowel and bladder: decreased

Sleep:adequate

History of toddy consumption occasionally 

TREATMENT HISTORY 

Uses diabetic medication

GENERAL EXAMINATION 

Patient was conscious,coherent  cooperative

Moderately build and moderately nourished

well oriented to time ,place and person

Pallor :  pallor,Lower palpebral congestion is seen 

Icterus: absent

clubbing: absent

cyanosis: absent

Lymphadenopathy: absent

Edema : pedal edema present pitting type

Vitals:

BP :110/80 mmHg

PR :80bpm

RR :17cpm

Temp: Afebrile

SYSTEMIC EXAMINATION

RESPIRATORY EXAMINATION 

trachea central,

normal respiratory movements,

normal vesicular breath sounds.

CARDIOVASCULAR SYSTEM

S1 ,S2 heard ,no murmurs

CNS EXAMINATION

CNS examination

No focal neurological deficits

PER ABDOMEN

soft non tender

PROVISIONAL DIAGNOSIS:

Chronic kidney disease and maintained under haemodialysis

Secondary to diabetic nephropathy

Anaemia secondary to CKD

Investigations :

Treatment:

Inj Erythropoetin

Inj Neomol

Tab lasix