GM case presentation 3

 30th September 2021

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A 62 year old female presented with complaints of pedal edema, shortness of breath, and decreased urine output since 4 days .

HISTORY OF PRESENTING ILLNESS:

 

Patient was apparently assymptomatic 11 months ago, then she developed lower back pain with early fatiguability. She went to a hospital in Khammam  and she was prescribed NSAIDS for 3 months. 

Then she then developed loss of appetite, early fatiguability, and swelling of hers arms and legs 7 months ago. These complaints were presented on 25th March 2021.

She developed S.O.B  3 months ago, with puffiness of face (entire face) and pedal edema.

• She was diagnosed with chronic kidney failure with acute febrile illness at Suryapet on the basis of her complaints as on 17th August 2021 being fever since 3days

S.O.B since 2 days.

She presented with:

• pedal edema   - pitting type

• decreased urine output since 4 days

• shortness of breath - since 4 days.

PAST HISTORY:

She is a k/c/o 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:

Appetite: decreased since 7months

Diet: mixed

Bowel habits: regular

Decreased urine output

Sleep: inadequate.

Addictions: Nil.

FAMILY HISTORY:

 

 No member in the family have similar complaints in the past .

No history of any cancer deaths in the family.

GENERAL EXAMINATION:

Patient is conscious, coherent, and cooperative

Moderately nourished and moderately built.

On the Consent of patient, she was examined in a well lit room.

VITALS:

HR: 101bpm | 98bpm

BP: 140/90 mmHg |  130/80 mmHg

RR: 31 cpm |  26 cpm

Temp: afebrile

SpO2 : 87 | 94 

Pallor: present

Icterus: x

Cyanosis: x

Clubbing: x

Lymphadenopathy: x 

Edema: pedal edema present 

SYSTEMIC EXAMINATION:

CVS: S1, S2 heard, no added murmurs

RS: B/L air entry present

       No abnormal sounds were heard.

CNS: All motor reflexes are normal

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