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
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