Case presentation 3

 5.10.21

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Date of admission:

Chief complaint:

A 60 year old female patient complaints of pedal edema, decreased urine output,shortness of breath since 4 days

HISTORY OF PRESENT ILLNESS:

 Patient was apparently asymptomatic 11 months ago and then she developed lower back pain with early fatiguability. She went to a hospital in Khammam where her X-ray chest and scans were normal and she was prescribed NSAIDS for 3 months. 

Then she then developed loss of appetite, early fatiguability, and swelling of her arms and legs 7 months ago.

She developed shortness of breath 3 months ago, with puffiness of face  and pedal edema 

She was diagnosed with chronic kidney failure with acute febrile illness at Suryapet on the basis of her complaints.

S.O.B grade 4 since 2 days.

 She has been undergoing dialysis in our hospital 

PAST HISTORY:

She is a known case of Hypertension, diagnosed 3 yrs ago.

She is using Atenolol since then. 

No history of DM/TB/Asthma/Epilepsy/Thyroid disorders

Past surgical history: she has undergone hysterectomy 10 yrs ago.

PERSONAL HISTORY:

Patient takes mixed diet with decreased appetite since 7 months.has regular bowel movements with decreased urine output.pt has no addictions.

FAMILY HISTORY:

No history of similar complaints in any member of the family.

GENERAL EXAMINATION:

Patient is conscious, coherent, and cooperative.Moderately nourished and moderately built.

Consent was taken and was examined in a well lit room.

VITALS:

Heart rate: 98 beats per min

BP: 130/80 mmHg

Respiratory rate: 26 cycles per min

Temperature:afebrile

SPO2 : 87

Pt show signs of Pallor,no icterus,no cyanosis,no clubbing,no lymphadenopathy,pt has bipedal edema of grade 2.

SYSTEMIC EXAMINATION:

CVS: S1, S2 heard, no added murmurs

RS: NVBS heard

B/L air entry present

No abnormal sounds were heard.

w r.t S.O.B Tachypnea is present

(S.O.B Grade 4)

CNS: All motor reflexes are normal

P/A: soft, non tender.

INVESTIGATIONS: (postive findings):

• Hb% - 6.6%

• Serum creatinine - 6.2 ( N = 0.74 - 1.35 mg/dl)

• Blood urea - 119 ( N = 5 - 20 mg/dl)

• On USG - B/L Grade 2 Renal pelvic diameter

- CMD (cortico-medullary differentiation) partially maintained.

• X-ray chest (PA view): 30/09/21

TREATMENT:

• low salt diet

• oxygen therapy (to control tachypnea)

• bicarbonate

• urine output management

• blood transfusion for Anemia (Hb-6.6%)

• dialysis  

Serum creatinine chart:

25/03/21 - 7.3 mg/dl

17/08/21 - 11.0 mg/dl

22/08/21 - 11.3 mg/dl

20/09/21 - 6.2 mg/dl