55 yr old Male with SOB and swelling

A 55 year old male came to the hospital with the chief complaints of shortness of breath since 10 days and swelling of legs since 10 days and low grade fever since 5 days
HOPI- patient was apparently asymptomatic 10 days ago, then he developed shortness of breath which is insidious onset, gradually progressive grade 2 aggrevated on exertion and relieved on taking rest, he developed edema of legs bilateral pitting edema, extending till knees aggraveted on walking and relieved on rest 
11/03/2021- one session of dialysis is done, edema of left leg is reduced
history of knee joint pains, morning stiffness+
history of trauma of the right upper limb at the level of shoulder joint while playing kabbadi
no history of chest pain and palpitations 
past history- he had similar complaints 1 month ago, he went to the hospital and got diagnosed as ckd and undergone dialysis-5 sessions.
18/03/2022 -dialysis done,
19/03/2022-No SOB,No joint pains,No morning stiffness.
history of dm since 3 years and on metformin 
history of htn since 6-7 months 
no history of tb,asthma, epilepsy, thyroid disorders 
personal history - patient was farmer by occupation, he used to go to his farm daily. He developed joint pains since last 7-8 months for which he is taking painkillers one or two daily( depending upon the severity of pain) diet-mixed, appetite-decreased, sleep- inadequate due to pain, bowel and bladder movements- regular
addictions- country liquor since 5 years due to stress and Beedi (daily 5) since 20 years
but stopped having any right now.
general examination-
patient is conscious coherent and cooperative, well oriented to time place and person 
pallor- present 
icterus- present 
cyanosis,clubbing, generalised lymphadenopathy- absent 
bilateral pitting edema present 
vitals- 
temp- afebrile
pulse rate-76bpm
blood pressure- 90/60 mm of hg
respiratory rate- 16cpm
grbs- 235 mg/dl
spo2-98%
systemic examination
cvs- s1,s2 heard no murmurs heard 
respiratory system- vesicular sounds ,crackles ?
per abdomen - no visible scars or sinuses, all quadrants are moving equal with respiration, no hernial orifices seen 
no dilated or tortuous veins
liver palpable, spleen not palpable
no tenderness
shifting dullness+
CNS - 
Minimental status examination- normal
cranial nerve examination- normal
motor system - bulk of muscles - bilaterally symmetrical
tone of muscles- decreased on right side
power of muscles 
                        right. left 
upper limb 4/5 5/5
lower limb 4/5 5/5
reflexes 
                  right. left
biceps + ++
triceps + ++
supinator ++ ++
ankle + ++
knee + ++
plantar. no response. no response
investigations- cbp,ldt,rft, usg, grbs
usg showed all 4 chambers of heart are dilated
provisional diagnosis- ckd due to nsiad induced nephropathy?
heart failure with reduced ejection fraction
mild ascites 
Learning objectives:
14/03/2021- patient is in altered sensorium, fever +, TLC-27000, urea-187mg/dl, creatinine-7.9 mg/dl
One session of dialysis was done yesterday morning
Urea after dialysis- 95 mg/dl, creatinine-4.1mg/dl
Learning objectives from class
AKI causes- prerenal- dehydration, heart failure, sepsis
Renal - ATN, GLOMERULONEPHRITIS,vasculitis
Post renal- bilateral urinary calculi
Bph, bladder cancer 
CKD criteria

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