27/10/2026
THIS PATIENT DATA GATHERED BY ROLL NO 14 BATCH 2023 AS PART OF HER COMPETENCE LEARNING BASED EVALUATION PORTFOLIO PRPARATION
THIS CASE IS OF 26M WITH FEVER AND SWELLING IN FEET SINCE 3 YRS
### CASE 1 - CKD STAGE 5 ON MAINTENANCE
*Case History*
- *Age / Sex:* 26 years / Male
- *Occupation:* Doing business
*Chief Complaints*
- Fever - 3 years ago
- Swelling in feet - 3 years ago
*History of Presenting Illness*
- Patient was overweight (82 kg) due to which he assumed he had breathlessness 4 years ago.
- Breathlessness increased when he was climbing stairs, decreased when sitting for 5-10 mins.
- Then 3 years ago, he developed fever which was for 3 days, it decreased while taking analgesics (Paracetamol) during night time.
- Then after fever subsided, patient saw swelling in his feet, associated with yellowish discoloration of feet and weight loss.
- He assumed it was jaundice.
- When he was asked to do his CBC, he had low hemoglobin.
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Personal History:
Diet - Mixed, advised to avoid red meat. Likes mutton, cucumber, mango, papaya, fruit. Appetite - Adequate.
Sleep - Disturbed while lying down, fullness around 2-3 am, wakes up in between.
Addictions - Nil
Used to consume outside food frequently before.
Family History - No similar complaints. H/o HTN in family. DM mother - 2 yrs, Father has...
General Examination:
Pt in C/C/C, well oriented to TPP
PICCLE - Pallor -, Icterus -, Cyanosis -, Clubbing -, Lymphadenopathy -, Edema -
Vitals - Pulse - 110/min, BP - 140/120 mmHg, SpO2 - 95%
Systemic Examination:
CVS - S1S2 +, No murmur
CNS - NFD
RS - NVBS
Abdomen - Soft, NT
Investigations:
Random Blood Sugar - 59 mg/dl
RFT - Urea - 122 mg/dl, Creatinine - 8.9 mg/dl
Provisional Diagnosis: Chronic Kidney Disease Stage 5
*Past History*
- No H/o Epilepsy / Asthma / TB
*General Examination*
- Patient conscious, well oriented to time, place, and person.
- Pallor: Absent
- Icterus: Absent
- Cyanosis: Absent
- Clubbing: Absent
- Lymphadenopathy: Absent
- Edema: Absent
*Vitals*
- Pulse Rate: 110 bpm
- Blood Pressure: 140/120 mmHg
- SpO2: 95%
*Systemic Examination*
- CVS: S1 S2 present, No murmur
- CNS: No focal deficit (NFD)
- RS: Normal vesicular breath sounds (NVBS)
- Abdomen: Soft, Non-tender
*Investigations*
- Random Blood Sugar: 59
- RFT:
- Urea: 122 mg/dl
- Creatinine: 8.9 mg/dl
- Hb - 6.5 gm
*Provisional Diagnosis*
- Chronic Kidney Disease
*History - Continued*
- Serum Creatinine: 13.4
- Then nephrologist advised to do dialysis.
- He was asked to limit water intake and salt intake.
- He developed breathlessness 1 year ago, which was not associated with chest pain nor swelling in feet.
- He was prescribed by cardiologist to take Sildenafil, Isosorbide dinitrate 20 mg.
- H/o Anuria since he is undergoing dialysis.
- H/o Breathlessness while lying down.
- He undergoes dialysis 3 days (alternate days) in a week.
- H/o Abdomen swelling when there is gap for 2 days (Saturdays & Sundays).
*Past History*
- No similar complaints 4 years ago.
- Known case of HTN since dialysis has started.
- No H/o DM / Asthma / Epilepsy.
- Gets fever rarely.
Here is a series of Socratic questions based on this case report, designed to prompt clinical reasoning and structured thinking for medical students:
1. History Taking & Symptom Correlation
* Breathlessness and Weight: The patient initially attributed his breathlessness to being overweight (82 kg). How can you clinically differentiate between dyspnea caused by deconditioning/obesity versus early cardiovascular or pulmonary compromise in a young adult?
* Fever and Jaundice Mimics: Following a brief fever, the patient noticed swelling and yellowish discoloration of his feet, which he assumed was jaundice. Why might pedal edema or chronic stasis changes sometimes be mistaken for jaundice by a patient, and what physical exam features distinguish true jaundice from local discoloration?
* Anuria and Dialysis: The patient developed anuria after starting dialysis and experiences abdominal fullness/swelling when there is a two-day gap over the weekend. What physiological mechanisms explain fluid accumulation and abdominal distension during interdialytic intervals?
2. Pathophysiology & Disease Progression
* Chronicity vs. Presentation: The patient presented with symptoms that started 3 years ago, yet was diagnosed with Chronic Kidney Disease (CKD) Stage 5. How is it possible for significant renal impairment to remain subclinical until late stages, and what are the classic warning signs that are often missed early on?
* Hypertension Dynamics: The patient developed hypertension after his dialysis started, and presented with a blood pressure of 140/120 mmHg. Is this severe elevation primarily volume-dependent, renin-mediated, or a combination of both in the context of end-stage renal disease?
3. Investigations & Interpretation
* Laboratory Findings: The patient's lab results showed a Serum Creatinine of 8.9 mg/dl (later 13.4 mg/dl), Blood Urea of 122 mg/dl, and Hemoglobin of 6.5 g/dl.
* How do you explain the presence of severe anemia (Hb 6.5 g) in the context of CKD Stage 5?
* Why might his random blood sugar be relatively low (59 mg/dl), and how does advanced kidney disease affect insulin clearance and glucose metabolism?
4. Management & Complications
* Cardiovascular Management: The patient was prescribed Sildenafil and Isosorbide dinitrate by a cardiologist. What specific pulmonary or cardiac complication of CKD or fluid overload is being targeted with these medications?
* Renal Replacement Therapy: Given that he is on maintenance hemodialysis three times a week, what are the critical patient education points regarding interdialytic weight gain, dietary restrictions (such as avoiding red meat and limiting water/salt), and access site care?
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