1601006132 - LONG CASE

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A 55 year old female ,homemaker ,residing in chityala, came to the hospital with chief complaints of 

1.Facial puffiness and Pedal edema since one month

2.decreased urine output since one month

3.shortness of breath since 20 days

HISTORY OF PRESENTING ILLNESS

•The patient was apparently assymptomatic 8 years back and then she developed facial puffiness and decreased urine output for which she was diagnosed as Chronic kidney disease.She was on medication for the same.

•one month back she developed facial puffiness and bilateral pedal edema which was pitting type , insidious in onset and gradually progressive to involve the whole body and was persistent and not relieved by medication.

•She also complains of decreased urine output since one month , associated with pain and burning sensation while micturition .

•She developed shortness of breath 20 days back which was insidious in onset and gradually progressed to grade 4.

•She also developed fatigue and numbness over the lower limbs since the past 20 days.

•She was advised to start with dialysis as her kidney function test were hampered.

•No history of fever,jaundice chest pain and palpitations.

PAST HISTORY

She is a known case of hypertension and diabetes  since 15 years and was on medication for the same.

She is a known case of chronic kidney disease since 8 years 

History of cataract 3 years back and was operated for the same.

FAMILY HISTORY

The is no relevant family history pertaining to the present illness.

PERSONAL HISTORY

She takes mixed diet

Appetite is decreased

Bowel and bladder movements are regular

Sleep is adequate

She has no addictions.

GENERAL PHYSICAL EXAMINATION

 The patient is conscious ,cooperative obese built and moderatly nourished ,oriented to time ,place and person.

Height :- 150 cm

Weight :- 73 kgs

BMI :- 32.4kg/m2

Pallor - present

Icterus - absent

Clubbing - absent

Cyanosis - absent

Koilonychia - absent

Lymphadenopathy - absent

Edema of feet - bilateral pitting edema present.

VITALS

Temperature - afebrile

Pulse - 80 beats per minute ,in radial artery

Blood pressure - 140/90 mm of hg in brachial artery ,supine position 

Respiratory rate - 18 beats per minute.

SpO2 -98%

GRBS - 116 mg/dl

HEAD TO TOE EXAMINATION

Anasarca 

Facial puffiness

Ascites

bilateral edema of the lower limbs

Skin - scaly lesions and excoriations 

extending from calf to foot on both the legs

Bilateral lower limb cellulitis (resolved)Ruptured diabetic bullae present on the feet.

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM 

inspection :-

      •chest is symmetrical in shape

      •Movement with respiration - normal respiratory rate (18 /min)with thoracoabdominal type of breathing.

      •trachea appears to be central 

      • no drooping of shoulders 

palpation :- 

     No tenderness

     No local rise of temperature 

     Apex beat felt in the left 5 th intercostal space 2.5 cm lateral to midclavicular line.

percussion :-

       Percussion along the mid clavicular line - dull note noted over the 3 rd ,4th ,5th ,6th intercostal spaces on both sides

Dull notes over the infraaxillary areas on both sides

auscultation:- 

 Bilateral crepitations were present 

CARDIOVASCULAR EXAMINATION

Precordium appears to be normal without any visible pulsations and engorged veins

ABDOMINAL EXAMINATION

inspection :-

•Shape- distended ,flanks full 

•Umbilicus is central in position

•Skin is stretched with striae

•No scars and sinuses

•No dilated veins

•Hernial orifices are normal

Palpation:-

•No tenderness 

•No local rise of temperature.

•Spleen and liver are not palpable

Percussion:-

•shifting dullness is present 

Auscultation 

Bowel sounds are heard.

CENTRAL NERVOUS SYSTEM EXAMINATION

the patient is alert 

Higher mental functions are intact

Cranial nerve examination  normal

Reflexes:-.         Right.            Left

Biceps.                +.                     +

Triceps.               +.                     +

Supinator.           +.                     +

Knee.                   +.                     +

Ankle.                  +.                     +

Plantar.                Flexor             flexor

INVESTIGATIONS

ULTRASOUND REPORT

chest X ray showing consolidations in both lung fields and cardiomegaly.

TREATMENT

Fluid and salt restriction 

Oxygen supplementation to maintain spO2 above 90%

Intermittent BiPAP

Tab. Nicardia 20 mg TID

Tab. Lasix 40 mg BD

Tab. Arkamine 

Tab. Met xl 50 mg BD

Tab. Nodisis 500 mg BD

Fusidic cream BD

Liquid paraffin OD

Strict intake /output charting 

Dialysis - 12 cycles were done

       Access - Carotid - jugular Av fistula.