Case discussion on CKD

1. CASE DISCUSSION
CHRONIC KIDNEY DISEASE
MODERATOR : DR. SARASWATHI
PRESENTER: DR. HARSHINI R

2. PATIENT DETAILS
• NAME: SELVI
• AGE: 55 YEARS
• SEX: FEMALE
• OCCUPATION: HOMEMAKER
• ADDRESS: BANGALORE, KARNATAKA
• SOCIO ECONOMIC STATUS: LOWER MIDDLE CLASS

3. CHIEF COMPLAINTS
ALLEGED HISTORY OF SELF FALL AND SUSTAINED INJURY TO LEFT HIP x
2 DAYS
COMPLAINTS OF PAIN, SWELLING AND INABILITY TO WALK SINCE 2
DAYS.

4. HISTORY OF PRESENTING ILLNESS
• Patient was apparently normal 2 days ago, when she had alleged
history of self fall at her home and sustained injury to her left hip.
• Patient developed pain, swelling and inability to move her left hip.
• There was no history of head injury, loss of consciousness, ENT bleed
or injury to other parts of the body.

5. • Patient is a known case of Chronic Kidney Disease since 2 years, after
she had complaints decreased urine output, bilateral lower limb
swelling and puffiness of face.
• She was admitted in the hospital for a period of 10 days where she
was managed with medications and 4 cycles of hemodialysis.
• After discharge, patient has been undergoing regular dialysis at her
local dialysis center 3 times a week, every week via a arterio-venous
fistula in her left forearm.
• Last dialysis was done yesterday.
• No history of decreased bp, breathing difficulty, itching or other
allergic manifestations, muscle cramps during dialysis.
• Patient has been advised to consume 1 litre of fluid per day.

6. • Patient has good effort tolerance, was able to climb two flights of
stairs.
• METS> 4
• No history of chest pain, palpitations or syncope
• No history of fever, recurrent upper respiratory tract infections.

7. PAST HISTORY
• Patient is known case of DIABETES MELLITUS since 10 years on
regular OHA medication.
• Known case of HYPERTENSION SINCE 10 years on regular medication.
• Not a known case of heart disease, asthma, TB, epilepsy.
• No history of previous surgeries, ICU stays.
• Habits- none
• No history of known allergies.

8. DRUG HISTORY
• Tablet METFORMIN- 500mg BD
• Tablet TELMISARTAN 20 mg OD
• Capsule CALCITRIOL 0.25 mg OD
• Inj. ERYTHROPOITEN 2000 units S/C weekly once.

9. PERSONAL HISTORY
• Sleep- normal
• Urine output- decreased.
• Bowel habits- normal
• Mixed diet
• Attained menopause 10 years back
FAMILY HISTORY-
Nothing significant.

10. SUMMARY
• A 55 year old female patient with a known case of Type 2 Diabetes
Mellitus, and Hypertension since 10 years o regular medication and a
known case of Chronic Kidney Disease since 2 years on regular
hemodialysis, presenting with fracture of left hip.

11. GENERAL PHYSICAL EXAMINATION
• Conscious, oriented and cooperative
• Moderately built and nourished
• Pallour- present.
• Bilateral pitting pedal edema- present
• No icterus, cyanosis, clubbing or lymphadenopathy.
• An AV fistula is present in the left forearm with positive thrill. No
other fistulas present.
• Height- 150 cm
• Weight- 65 kg

12. AIRWAY EXAMINATION
• Facies normal
• External nares normal.
• Mouth opening- >3cm
• Mallampatti- grade 2
• Thyromental distance- >6 cm
• Tempero mandibular joint mobile and can insinuate one finger
• Neck extension, flexion within normal limits.
• Prayer sign- negative
• Palm print sign- grade 0

13. VITALS
• PULSE- 80 BPM, regular rhythm, normal volume and character and
condition of vessel wall is good. All peripheral pulses felt. No radio-
radial or radio- femoral delay.
• BLOOD PRESSURE- 132/88 mmhg in supine, 128/80 mmhg in
standing.
• RESPIRATORY RATE- 15 cpm, regular, abdomino thoracic. Heart rate
variability to respiration is normal
• TEMPRATURE- 37.8° C
• SPO2- 99% in room air.

14. SYSTEMIC EXAMINATION
ABDOMEN
1. INSPECTION
o Not distended
o Umbilicus is midline
o All quadrants move equally with respiration
o No visible scars, sinuses/ distended veins.
2. PALPATION
o Soft non- tender. No guarding or rigidity
o No organomegaly
3. PERCUSSION
o No fluid thrill, no shifting dullness
4. AUSCULTATION
o Normal bowel sounds heard.

15. CARDIOVASCULAR SYSTEM
1. INSPECTION
oTrachea is in midline
oChest wall appears normal
oNo visible pulsations
2. PALPATION
oApical impulse felt in left 5th intercostal space half an inch lateral to mid-
clavicular line.
oNo thrill or parasternal heave
3. AUSCULATATION
oS1S2 heard in aortic, pulmonary, tricuspid and mitral area.
oNo murmurs

16. RESPIRATORY SYSTEM
1. INSPECTION
o Trachea is midline
o Chest wall appears normal
o No scars, sinuses or engorged veins
2. PALPATION
o All inspector findings confirmed
o Chest expansion equal on both sides
o Vocal fremitus equal on both sided
3. PERCUSSION
o All lung fields resonant
4. AUSCULTATION
o Normal vesicular breath sounds heard in all lung fields
o No added sounds.

17. • CENTRAL NERVOUS SYSTEM
oHigher mental functions normal
oCranial nerves normal
oSensory and motor functions normal
oNo glove and stocking type of peripheral neuropathy.

18. LOCAL EXAMINATION
Done in supine position
Gait- could not be assessed.
Attitude- patient is in supine position. ASIS at same level with limb in
external rotation.
INSPECTION
oASIS at same level
oThere is apparent shortening of left limb
o skin appears normal.

19. PALPATION
Tenderness present at midinginal point.
No local rise of temperature.
MOVEMENT
Could not be assessed due to pain.
MEASUREMENT
True length- right- 72cm, left- 71cm

20. PROVISIONAL DIAGNOSIS
A 55 year old female patient with known case of Type 2 Diabetes
Mellitus and Hypertension on regular medication, and known case of
Chronic Kidney Disease on regular hemodialysis presenting with
fracture neck of femur posted for proximal femoral nailing of left hip.

21. THANKYOU