62,F with CKD presenting with SOB
30th September 2021
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
A 62 year old female presented with complaints of pedal edema, shortness of breath, and decreased urine output
K.Medha Reddy, 9th semester.
Roll No: 51
I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
CASE :
A 60 year old female came to the casualty at 6:30 PM with
C/C:
• pedal edema
• decreased urine output
• shortness of breath
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 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 hers arms and legs 7 months ago. These complaints were presented on 25th March 2021.
On 25/03/21, her investigation reports were as follows:
Serum creatinine : 7.2 mg/dl
Blood urea : 147 mg/dl
BUN : 69 ( N = 8 - 23 mg/dl)
Hb% : 6.8 mg/dl
• She developed S.O.B 3 months ago, with puffiness of face (entire face) and pedal edema (putting typer grade 2).
• 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 grade 4 since 2 days.
• Investigation to support: as on 17th August:
On general examination:
BP : 120/80mmHg
Pallor: +. ; Crepts: + ; Pedal edema: +
- serum creatinine : 11.0 mg/dl.
- Total WBC : 42,000 ( N = 4,000 - 10,000)
Treatment undergone:
Low salt diet less than 3g/d
Fluid intake less than 1 lt/d
Inj. Zostum 1.5gm BD
T.sodocel thrice a day
T. Phostat 400mg at afternoon with food
T. Calci-cz once every alternate day
T. Dytor 100mg OD
Inj. H.erypro 4000U SC thrice in a week.
On 22/06/21 when reviewed her,
Serum creatinine is 11.3 mgldl and was advised regarding need for initiation of RRT (Renal Replacement Therapy)
And she was transferred to our hospital.
She presented with:
• pedal edema - grade 2
- pitting type
• decreased urine output since 4 days
• shortness of breath - since 4 days.
- grade 4
- orthopnea : +
She has been undergoing dialysis in our hospital since then.
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 7mo
Diet: mixed
Bowel habits: regular
Decreased urine output
Sleep: decreased due to shortness of breath, and pain due to central line.
Addictions: Nil
FAMILY HISTORY:
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:
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 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
Orthopnea/PND - 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
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