62,F with CKD presenting with SOB

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

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