26M DECREASED URINE OUTPUT SINCE 2 DAYS, BREATHLESSNESS SINCE 3 DAYS

 

29/10/2026

THIS PATIENT DATA WAS GATHERED BY ROLL NO 12 BATCH 2023 AS PART OF HER COMPETENCE BASED LEARNING EVALUATION PORTFOLIO PREPARATION.

THIS IS THE CASE OF 26M WITH DECREASED URINE OUTPUT SINCE 2 DAYS, BREATHLESSNESS SINCE 3 DAYS AND MILD SWELLING IN BOTH FEET SINCE 3 DAYS

*Demographics*

- *Age / Sex:* 26 years / Male

- *Occupation:* Businessman

*Chief Complaints*

- Urine output decreased since 2 days

- Breathlessness since 3 days

- Swelling (mild) on both feet since 3 days

*History of Present Illness*

- Patient was apparently asymptomatic 3 years ago, then he was diagnosed with hypertension, CKD and hypertension.

- 3 years ago, he developed mild bilateral pedal edema, initially involving ankles and progressing to leg.

- Swelling was insidious in onset, gradually progressive, bilateral edema (non-pitting), relieved by rest.

- 3 years ago, he noticed oliguria, progressive in nature. No history of hematuria.

- Since 3 years ago, he was diagnosed with CKD on blood test. Since then, he has been taking hemodialysis - since one and half year, 2 times / week, through AV fistula.

*History of Present Illness - Continued*

- No history of fever, productive cough, chest pain.

*Past History*

- *Known case of:* Hypertension - 3 years

- *CKD - 3 years:* Hemodialysis

- *No history of:* TB, Asthma, COPD

*Personal History*

- *Appetite:* Decreased

- *Diet:* Mixed

- *Sleep:* Disturbed

- *Bowel & Bladder:*

    - *Bowel:* Regular

    - *Bladder:* Oliguria - 200 ml / day

- *Addiction:* No

*Family History*

- No significant family history

*General Examination - On Examination*

- Patient alert, well oriented to time, place, person

*PICCLE:*

- *P - Pallor:* Present (+)

- *I - Icterus:* Absent

- *C - Cyanosis:* Absent

- *C - Clubbing:* Absent

- *L - Lymphadenopathy:* Absent

- *E - Edema:* Present (+) - Pedal edema, pitting edema

*Vitals*

- *BP:* 160 / 90 mmHg

- *RR:* 20 / min

- *Temp:* 98°F

- *SpO2:* 94% on Room Air

*Systemic Examination*

- *CVS:* S1 S2 present (+)

- *CNS:* NFND - No Focal Neurological Deficit

- *RS:* NVBS BAE (+) - Normal Vesicular Breath Sounds, Bilateral Air Entry present

- *P/A:* Soft, Non-Tender

*AV Fistula Examination - Cephalic & Radial Vein*

*Inspection:*

- Surgical scar

- No prominent vein

- No redness

*Palpation:*

- Palpable continuous thrill

- Mild swelling present

Here is a set of Socratic questions based on the clinical case of the 26-year-old male with chronic kidney disease (CKD) and hypertension, tailored for medical student learning and clinical reasoning:

1. Pathophysiology & Clinical Presentation

 * Question: The patient presents with oliguria (decreased urine output) of 200 mL/day and bilateral pedal edema. How do the kidneys' loss of autoregulation and glomerular filtration rate (GFR) over time explain both the oliguria and the development of non-pitting/pitting edema?

 * Question: He has a 3-year history of hypertension. In a young patient like this, is the hypertension more likely the cause (hypertensive nephrosclerosis) or the consequence of his CKD? How would you differentiate between the two?

2. Complications & Symptoms

 * Question: The patient complains of breathlessness of 3 days' duration alongside an SpO2 of 94% and normal vesicular breath sounds. Given his underlying CKD and oliguria, what fluid and acid-base disturbances are top differentials for causing his dyspnea?

 * Question: General examination notes the presence of pallor (+), but no history of acute blood loss or hematuria. What is the primary mechanism of anemia in chronic kidney disease, and why does it manifest insidiously?

3. Management & Renal Replacement Therapy

 * Question: The patient has been on hemodialysis twice a week for the past 1.5 years via an AV fistula. What physical examination findings should you expect when palpating a healthy, functioning AV fistula (e.g., cephalic/radial vein), and what does the presence of a continuous thrill indicate?

 * Question: Why might a patient who is already compliant with regular hemodialysis suddenly present with acute oliguria and worsening fluid overload symptoms over the last 2 days? What precipitating factors must you rule out (e.g., dietary indiscretion, access thrombosis, non-compliance, or infection)?

4. Diagnostic & Investigative Approach

 * Question: Beyond routine serum creatinine and blood urea nitrogen (BUN), what immediate electrolyte panel (and specific ECG changes) is most critical to check first in an oliguric CKD patient presenting with breathlessness?

 * Question: What would you expect renal ultrasound findings to show regarding kidney size and corticomedullary differentiation in a patient with a 3-year history of advanced CKD compared to acute kidney injury (AKI)?