65Y/F CKD 2° MHD

WARD CASE - 11th September 2023

A 65 year old uneducated lambadi woman a resident of Bhongir , working as a daily wage worker since 40 years earning 250 rupees a day , belonging to low socioeconomic status according to modified kuppuswamy scale presented to the general medicine OPD with chief complaints of :
- swelling in both the legs since 15 days 
- cough and shortness of breath since 10 days 
 
History of presenting illness 
Patient was apparently asymptomatic 6 months ago , when she developed swelling in the lower limbs which was insidious in onset and gradually progressive , it was associated with pain which was dragging in type and aggraveted on walking and working and was relieved on rest.
-not associated with trauma 
-not associated with any joint pains 
-no history suggestive of previous filarial infection
she was diagnosed with renal failure secondary to hypertension and started on dialysis 
 
She has swelling of the lower limbs since 15 days which was insidious in onset and progressive in nature and is associated with dragging type of pain with is localisd to the areas of swelling , it is aggravated on walking and noy relieved on rest and elevation of legs
associated with dry skin 
associated with itching 
no h/o lower limb discoloration
no h/o trauma 
She also reports episodes of cough , the cough is non-productive and increased at early morning
history of weight loss of 15 kgs in 6 months 
no h/o evening rise of temperature 
no h/o abdominal pain
She also reports shortness of breath which corresponds to MMRC grade 3
(breathless on walking 100m at the same level)

Past History 
history of similar complaints 6 months ago 
known case of hypertension since 6 months 
on regular dialysis 
n/k/c/o DM, asthma, Tb , epilepsy 

Treatment history 
Regular dialysis 

Personal history 
Diet : mixed 
Appetite : loss of appetite since 15 days 
bowel : normal and regular 
bladder : reduced urine output , burning micturition (occasionally )
addictions : not known 
allergies : not known

Family history 
not significant 

EXAMINATION
General Examination
Patient was c/c/c and was oriented to space ,time and person 
moderately built and adequately nourished  
vitals
pulse rate : 70 bpm 
BP :  130/80 mmHg 
gross examination
PALLOR : present 





cyanosis , clubbing , generalised lymphadenopathy are all absent 
PEDAL EDEMA : Present uptill knee joint - 3 ; pitting in type 






Systemic examination

-Respiratory system

inspection 
-subcoastal retrations present
-respiratory rate : 19 cpm 
-no gross abnormality of chest wall
 -no engorged veins or sinuses present 
ausculation
 BAE +
vesicular breath sounds
rhonchi heard in the right lower lobe 
percussion 
dullness in the right lower lobe 
-tympanic note in the left upper and lower areas 
palpation
trachea present in midline 
lungs are expanding equally on inspiration

-PA 
-soft and non tender 
no organomegaly 
normal bowel sounds heard 

CVS 
Inspection
no gross chest wall abnormality 
palpation
Apex beat was faintly felt at left 4th intercoastal space 
ausculation
S1 S2 heard 
no abnormal sounds heard

CNS 
 tremor of the hands was seen 



no focal neurologic deficit 
no signs of meningial irritation
no gait abnormality 

Provisional diagnosis 
pleural effusion of right lung secondary to CKD 
 
treatment 
-nicardia 
-nodosis
-lasix
-shelcal 
-salt restriction
-budesonide nebulization

follow up 
12/11/2023 

Patient reports fever and chills 
Fever was intermittent in Type , and associated with chills and rigours, she reports profuse sweating in the nights 
It was associated with diurnal variation , increase of temperature during the day time 

Patient also reports feeling breathless during the night time , with is increasing on supination and relived on sitting 

Examination 
Febrile : 100.4 Fahrenheit 
Auscultation:  Rhonchi heard in the right lower lobe and crackles heard in the left upper and lower lobes 






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