67 year old female patient with CKD

[ SHORT   CASE ]

January 19, 2023

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CHEIF COMPLAINT:-

A 67 years old female presented to the OPD with chief complaint of Shortness of breath since  3 months ,Decreased urine output since 3 months, Pedal edema since 3 months .

HISTORY OF PRESENT ILLNESS:-

Patient was apparently asymptomatic for a year before she observed a decrease in urine output, was diagnosed with heart failure, and started taking medication for both. Then, 3 months ago, she began to experience significant bilateral pedal edema, of the pitting type, expanding to her ankles and steadily worsening from grade 2 to grade 3 until finally subsiding. Slight stinging while urinating and on medication for diabetes.

No history of PND,Cough,Cold,Fever

HISTORY OF PAST ILLNESS:-

K/C/O Hypertension since 30 years,Tab arkamine,nicardia 20mg

 Diabetes mellitus since 30 years,Tab glimi 3mg/PO/BD

Not known case of asthma, tuberculosis, epilepsy.

PERSONAL HISTORY:-

 Diet - Mixed

Appetite - Lost 

Bowel - constipation

Bladder movement - Irregular 

Micturition - slight burning 

Sleep - Adequate

No addictions.

FAMILY HISTORY:-

No known member of the family has similar Complaints

GENERAL EXAMINATION:-

Patient is conscious, coherent,co-operative 

Well oriented to time and place. 

No  ,icterus, cyanosis ,clubbing, lymphadenopathy,  pedal edema.

Pallor is present 

VITALS :-

Temperature - Afebrile 

Bp - 160/100mmhg

Pulse rate - 100/min

Respiratory rate - 16 cycles / min.

SYSTEMIC EXAMINATION:-

RESPIRATORY SYSTEM:-

Inspection:-

Chest is  bilaterally symmetrical  

Movements are bilaterally symmetrical.

Position of trachea Is central

No Sinuses,Scars,Fistulas

Palpation:-

ALL INSPECTORY FINDINGS ARE CONFIRMED BY PALPATION.

Local rise in temperature: No

Non tender

Apex beat felt in 5th intercostal space 2cm lateral to midclavicular line .

Percussion:-

Resonant sound is heard

Auscultation: 

Normal vesicular sounds are heard.

CARDIOVASCULAR SYSTEM:-

Inspection:-

Bilaterally symmetrical chest

No visible engorged veins,scars or sinuses on chest.

Palpation:-

S1 S2 are heard

No thrills , no murmurs 

Apex beat present at 5th intercostal space 2cm lateral to midclavicular line .

Auscultation:-

Cardiac rate - 100 beats per minute 

No cardiac murmurs heard.

 

ABDOMEN:-

Inspection:-

Shape of the abdomen -distended

Flanks- full

Umbilicus - central and inverted 

Sinuses and scars - not visible

No dilated veins

Palpation:-

No local rise in temperature

No tenderness

No palpable mass

No organomegaly

Hernial orifice -normal

Free fluid - yes

No bruits

Liver not palpable

Spleen not palpable

Percussion:-

Shifting dullness positive

Auscultation:-

Bowel sounds heard

CENTRAL NERVOUS SYSTEM:-

Conscious, speech is normal

No neck stiffness 

Kernings sign - negative

Memory intact

Cranial nerve normal

Motor sensory nerves normal

PROVISIONAL DIAGNOSIS:-

Chronic renal failure 

Anemia

Resolved heart failure

INVESTIGATION:- 

USG ABDOMEN:

 

2D echo:

Complete blood picture:

Complete urine examination:

Random blood sugar:

Serum creatinine :

Serum electrolytes:

ECG:

TREATMENT:- 

Hemodialysis

Inj frusemide-40 mg/Iv/Tid

Tab:Nicardia-10 mg/Po/Tid

Tab Nodosis 500 mg/Po/Tid 

Tab shelcal-500 mg/Po/OD

Inj.pan-50 mg/iv/OD

Tab orofer-Po/OD

Cap BioD3-Po/OD

Inj Erythropoietin-4000iu weekly once

Inj iron sucrose-100 mg/iv in 100 ml NS weekly once