50F CKD WITH PEDAL EDEMA

 29/10/2026

THIS PATIENT DATA WAS GATHERED BY ROLL NO 8, BATCH 2023 AS PART OF HER COMPETENCE BASED LEARNING EVALUATION PORTFOLIO PREPARATION

THIS IS THE CASE OF A 50F HOUSEWIFE WITH CKD, PEDAL EDEMA 1 YR, URINE OUTPUT DECREASED 5 DAYS, PITTING EDEMA.

Demography: 50 yrs / Female / Housewife

Date: 20/10/2026

Chief complaints:

- Edema (swelling of legs - 1 yr)

- Urine output decreased - 5 days

- Pitting edema

HOPI:

Pt was apparently asymptomatic 2 yrs ago then she diagnosed with hypertension and CKD. 1 yr ago she developed mild bilateral pedal edema, initially involving ankle & progressive to leg. Swelling was insidious on onset, gradually progressive, bilateral edema, non pitting, relieved by rest.

1 yr ago she noticed oliguria, progressive nature. Since 8 months ago she was diagnosed with CKD by blood test, 2 times/wk, 4 hrs per session through AV fistula.

Past H/O:

K/C/O HTN since 2 yrs, CKD for 2 yrs - on haemodialysis

N/K/C/O - TB, asthma, epilepsy

Personal H/O:

Appetite ↓, Diet - mixed, Sleep - disturbed, Bowels - normal, Bladder - oliguria - 200 ml/day, Addiction - No

*Family H/o = NO*

*General Examination : O/E*

Pt is C/C/C well oriented to T/P/P.

*P I C C I E*

(-) (-) (-) (-) (-) (+)

Pedal Edema

↓

Pitting edema

*Vitals:*

BP - 160/90 mmHg

RR - 29/min

Temp - 98F

SpO2 - 99% on RA

*Systemic Examination*

CVS - S1 S2 (+)

CNS - NFND

RS - NVBS, BAE (+)

P/A - Soft NT

*AV Fistula examination (Cephalic & Radial vein artery)*

Inspection: surgical scar

No prominent

No redness

Palpation: palpable continuous /

mild, swelling present.

Provisional: CKD Stage 5D on MHD - For AV fistula assessment

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Here is a set of Socratic learning questions based on the clinical case of the 50-year-old female with chronic kidney disease (CKD) on maintenance hemodialysis:

Socratic Clinical Reasoning Questions

1. Pathophysiology & Clinical Presentation

 * Question: The patient presented with a 1-year history of progressive, bilateral pitting pedal edema and a 5-day history of decreased urine output (oliguria, ~200 mL/day). How do failing homeostatic mechanisms in Stage 5 CKD directly contribute to fluid overload and the specific physical finding of pitting edema?

 * Question: Her blood pressure was recorded at 160/90 mmHg with a 2-year history of hypertension. Is the hypertension in this patient more likely a cause of her nephropathy, a consequence of advanced renal failure (such as volume overload and renin-angiotensin-aldosterone system activation), or both? Explain the cyclic relationship.

2. Management & Renal Replacement Therapy

 * Question: The patient undergoes maintenance hemodialysis (MHD) twice a week for 4 hours per session via an arteriovenous (AV) fistula. Why is an AV fistula preferred over central venous catheters for long-term hemodialysis access, and what specific physical exam findings should you look for during an assessment to ensure its patency (e.g., thrills and bruits)?

 * Question: Given her severe oliguria (200 mL/day) and reliance on hemodialysis, how would fluid and dietary restrictions (specifically regarding sodium and potassium intake) be calculated between dialysis sessions to prevent acute pulmonary edema or hyperkalemia?

3. Complications & Differential Diagnosis

 * Question: Patients with end-stage renal disease (ESRD) experience multi-organ system impacts. Beyond fluid management, what key electrolyte disturbances (e.g., potassium, calcium, phosphate) and hematologic complications (e.g., normocytic anemia due to decreased erythropoietin production) would you anticipate monitoring in this patient?

 * Question: If this patient suddenly presented with altered mental status or acute neurological symptoms, what metabolic encephalopathies or uremic complications would need to be immediately ruled out?