73 YR OLD WITH DECREASED URINE OUTPUT

 

 This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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.  

CASE:

73 YR Old farmer came with the chief complaints of swelling of the legs and decreased urine since 1month and shortness of breath since 3 days

HISTORY OF PRESENT ILLNESS:

He was apparently asymptomatic 1 month back and then developed decreased urine output which is insidious in onset gradually progressive amber color non foul smelling not associated with pus and blood in the urine and not associated with burning micturition.

h/o swelling of legs since 1 month which is insidious in onset and gradually progressive pitting type present in both the legs from foot till ankle.

h/o shortness of breath since 3 days which is insidious in onset gradually progressive from grade 3 mMRC to grade 3 mMRC not associated with postural and diurnal variation 

no h/o chest pain, orthopnea, paroxysmal nocturnal dyspnea, sweating, palpitations.

h/o fever since 1 day which is insidious in onset gradually progressive with evening rise of temperature, not associate with chills and rigor.

no h/o blurring of vision, dizziness, paraesthesias, limbs weakness, facial weakness

PAST HISTORY:

No h/o similar complaints in the past

h/o hypertension since 10 yrs

no h/o diabetes, asthma, tb, cad, thyroid disorders in the past

PERSONAL HISTORY:

Diet: mixed

Appetite: normal

sleep: adequate

bowel and bladder movements are regular

h/o alcohol intake 150 ml per wk for 30 yrs

h/o smoking 10 ciggaretes per day for 30 yrs

FAMILY HISTORY:

No relevant family history

DIAGNOSIS BASED ON HISTORY:

Renal failure

urinary tract infection

urinary strictures

hydronephrosis

renal caliculi

urinary bladder caliculi

GENERAL EXAMINATION:

He is conscious, coherent, cooperative and well oriented to time, place, person.

thin built and moderately nourished

pallor and pedal edema present

no icterus, cyanosis, clubbing, lymphadenopathy

VITALS:

Temperature: febrile

pr: 100bpm

rr: 20cpm

bp: 150/90 mm hg

SYSTEMIC EXAMINATION:

ABDOMEN EXAMINATION: shape is flat, umbilicus is central and inverted and flanks are free, hernial orifices are intact, Non tender, no organomegaly, no fluid thrill, no shifting dullness, no puddle sign, auscultopercuusion negative, normal bowel sounds 6 per minute and no bruits and venous humms.

CARDIOVASCULAR EXAMINATION: s1 and s2 heard, no murmurs and added sounds heard

RESPIARATORY EXAMINATION: B/L air entry present, trachea is central, on percussion stony dull note on lt axillary infraaxillary, mammary and infrascapular regions. decreased breath sounds in the above mentioned areas.

NERVOUS SYSTEM EXAMINATION: No focal neurological deficits.

PROVISIONAL DIAGNOSIS; Chronic kidney disease

INVESTIGATIONS: