Chronic renal failure

A 60 yr old male mesthri by occupation came to casualty 29/11/2020 at time 5:30 pm with complaints of shortness of breath since 3 days & complaint of decreased urine output since 3 days .Headaches and earache since 3 days 

Patient was apparently asymptomatic 18 yrs back   and one day he is lifting granite stones and then suddenly bent and fell down(slip/unconscious)which is  diagnosed  to be traumatic paraplegia for which cervical cord decompression is done then 12 yrs back  he had complaints of    polyuria , weakness  burning sensation of feet for which he was diagnosed to be diabetic and then 6 months back  he developed pedal edema  Pitting type ( grade 1) ,on and off subsided by morning on its own 

They when to hospital for checkup and with creatinine 5.0 and used some medication diagnosed as CKD  and used Lasix for treatment 

History of presenting illness  

Patient came with complaints of shortness of breath since 3 days increased during night 

Increased during supine position,  pedal edema (grade 2)  which is progressive( left greater than right) increased in the evening decrease in the morning.

Past illness  known case of DM 2 since 12 yrs on oral hypoglycemia drugs for 9 years and on insulin for 3 years, not a known case of Hypertension, Asthma, TB,CAD

Personal history: 

Appetite: normal

Bowels: regular 

Bladder- normal micturition

Additions : drinks alcohol daily 90 ml since 25 yrs , smokes beedi 10~12 /day since 25 yrs 

Family history:History of DM, & CVA 

No history of HTN CAD, asthma   in the family

General examination: patient is conscious, coherent, cooperative 

Pallor is seen.

clubbing present

No icterus, cyanosis, 

lymphadenopathy, edema

Vitals:

Temperature: 98.9F

Pulse: 90bpm

Respiratory rate: 19/ min

Bp: 130/90mm hg

Spo2: 98% at 6 ltrs of oxygen 

Systemic examination: 

Cvs: S1 S2 heard no additional sounds or murmurs

Rs: NVBS

Abdomen: soft,non tender

Cns: higher mental functions 

Provisional diagnosis: 

Chronic renal failure. 


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