60 yrs female with chronic kidney failure

 N.sahithi 

9th semester 

Roll no: 96

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 60 year  female homemaker , from miryalaguda came to us on 29th with

Pedal edema since 15days

.Easy fatigability since 15 days.

.Swelling of hands and feet and face since 13 days.

Shortness of breath since 5days grade 4

History of present illness:

*Patient was apparently asymptomatic 15days ago then She developed pedal oedema sudden in onset and gradually progressive.

 *And 2days later edema of  hands and face.

*She developed sob initially grade 2 and  progressed to grade 4.

*Decreased urine output since 4days.

 complained of aggravating pain in the BILATERAL KNEE JOINT.  Since a week.

*Since 3 days she was unable to walk , unable to do her daily chores and unable to talk properly (slurred speech).

*{?UREMIC ENCEPHALOPATHY} (blood urea: 154 mg/DL) 

*Shortness of breath increased and she was presented to us on the morning of 29/3/2022.

 
*No H/O Burning micturition, hematuria , fever

Event time line:

*The patient had a traumatic experience an year ago where she lost her son! Since then , patient started sleeping for longer time and also increased snoring  since an year ( as said by the daughter ).

*3 months ago , she started consuming protein powder for weight loss , she used to consume only one meal a day that is in the afternoon and used to drink protein powder both morning and evening. 

No h/o exercising** .

(Replaced her morning and evening meals with protein powder ) 

*After fracture she stopped taking protein powder .

*2 months ago : H/O  fall due to sudden loss of balance breaking her left wrist for which she went to a local RMP and was suggested an Ayurvedic slab for the left wrist ! 

*15 days ago :  she went for the removal of the Ayurvedic slab .

*2days back she came to hospital with above symptoms . 

 Past history:

*She is known diabetic and hypertensive for the past 14 years and on regular medication. 
On Telma H 40mg and on Azulix 1 MF ( glimiperide + metformin) .

*Fracture of left wrist 1month ago.

*Right eye cataract surgery 1yr back. 

*No history of thyroid , asthma, heart diseases. 

Personal history:

*Her appetite is reduced since 5 days

*She takes a mixed diet

*Her bowel and bladder movements are regular

*Sleep is prolonged

*Urine output is reduced

*No known allergies 

*No known addictions

Family history:

*Her elder brother passed away in a heart attack at the age of 40 years old.

*Her younger brother is a known case of diabetes.

Menstrual history:

*Menarche at 13 years of age.

*Tubectomy was done 27 years back.

Vitals : (30/3/22)

*Temperature: afebrile (98.3 degrees F) 

*Pulse rate: 91bpm 

*Respiratory rate :21cpm 

*Spo2: 88 @ R.A , 96 on 11 lit O2 

*Blood pressure : 180/110 

Vitals : (31/3/22)

Patient is non conscious intubated  today morning  

*Temperature: afebrile (98.3 degrees F) 

*Pulse rate: 94bpm 

*Respiratory rate :24cpm 

*Spo2:  96 on 11 lit O2 

*Blood pressure : 60/40

GENERAL PHYSICAL EXAMINATION: 

*Patient is conscious /coherent /cooperative 

*On examination;:

Pallor : present 

Icterus : No

Cyanosis : no

Clubbing: no

Lymphadenopathy: no

*Clinical pictures:

SYSTEMIC EXAMINATION : 

CARDIOVASCULAR SYSTEM

INSPECTION:

Chest wall - bilaterally symmetrical

No dilated veins, scars, sinuses

PALPATION:

Apex beat shift to 6th intercostal space .

No parasternal heave, thrills felt.

PERCUSSION:

Right and left heart borders percussed.

AUSCULTATION:

S1 and S2 heard , 

RESPIRATORY SYSTEM

INSPECTION:

Chest is bilaterally symmetrical

Trachea – midline in position.

Expansion of chest bilaterally equal 

No dilated veins, scars, sinuses.

PALPATION:

Trachea – midline in position.

Apical beat shifted to left 6th intercoastal space.

Chest is moving equally on respiration on both sides

PERCUSSION:

The following areas were percussed on either sides- 

Mammary dull

Infraaxillary dull

Infrascapular dull

Remaining areas resonant.

AUSCULTATION:

bilateral crepts  heard 

ABDOMEN EXAMINATION

INSPECTION:

Shape – scaphoid

Flanks – free

Umbilicus –central in position , inverted.

All quadrants of abdomen are moving with respiration.

No dilated veins, hernial orifices , sinuses

No visible pulsations

PALPATION:

Soft, non tender

Spleen liver kidney not palpable

PERCUSSION:

There is no fluid thrill , shifting dullness

AUSCULTATION:

 Bowel sounds are heard

CNS: NAD ( ?dysarthria due to ?high urea levels?) 

RS: BAE+ , ? 

Investigations:

Provisional diagnosis :

 CHRONIC RENAL FAILURE ? uremic encephalopathy ? Diabetic neuropathy.

 

Treatment:

1)  TAB . Lasix 40 mg PO/BD 
2) TAB. Nodosis 500 mg PO/BD 
3) TAB. Shelcal CT 500 mg PO / OD 
4) TAB. Orofer XT 1 tab PO /OD 
5) TAB. PAN 40 mg PO/OD 
6) INJ. Erythropoietin 4000 IU SC. Weekly once
7) TAB. Nicardia 20 MG PO/TID