22 year old female with edema and decreased urine output
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FINAL EXAMINATION SHORT CASE REPORT.
Hall ticket no:1701006153
Batch :2017
CASE
22 year old female , farmer by occupation, resident of Miryalguda came with chief complaints of
• Decreased urine output since 5 days
• Generalised edema since 5 days.
HISTORY OF PRESENTING ILLNESS
• She was apparently asymptomatic 12 years ago when she developed increased frequency of micturition , increased appetite , fever for 10 days for which she went to a private hospital in miryalaguda . She was diagnosed with Diabete mellitus.
• She was on oral hypoglycaemic agents for 1 year then she was kept on insulin 2 times daily.
•During routine checkup she was diagnosed with hypertension 1 year ago , from then she is on tab.Telma and tab.Nicardia.
• 15 days ago she was brought to opd with generalised edema , grade 3 dyspnoea, increased dyspnoea on lying down, decreased urine output was diagnosed with renal failure and nephrotic syndrome.
• She was hemodialysed for 5 times and blood transfusion of 1unit was done and was discharged.
•She was again admitted due to decreased urine output and generalised edema since 5 days. Periorbital edema appeared first then whole body was involved.
•No history of hematuria , loin pain. No history of sore throat and fever. No history of cough.
PAST HISTORY
•Patient is a known case of diabetes mellitus since 12 years and is on insulin two times a day.
• Also a known case of hypertension since 1 year and is on tab.telma and tab.Nicardia.
• No history of asthma, epilepsy, tuberculosis,coronary artery disease.
• No history of any surgeries.
PERSONAL HISTORY
•Diet : mixed
• Appetite: decreased since 1month
• Sleep: adequate
• bladder : decreased urine output since 20 days.
• Bowel : regular.
• No addiction.
• No allergies.
FAMILY HISTORY
Not significant
MENSTRUAL , MARITAL AND OBSTETRIC HISTORY
Menarche at 11 year age.
Regular cycles 5/30.
No pains and no clots.
Married 1 year ago
2 months of amenorrhea 3 months ago .
She was pregnant and diagnosed based on usg ,but no fetal cardaic activity so she was aborted.
From then she had no menstrual cycles.
GENERAL EXAMINATION
Patient is examined in a well lit room after taking consent .
She is conscious, coherent and cooperative.
Oriented to time,place and person.
Pallor - present.
Icterus - absent.
Cyanosis- absent.
Clubbing- absent.
Lymphadenopathy- absent.
Edema- pitting type of bilateral pedal edema and generalised edema (anasarca) present.
Pallor:
Edema:
VITALS:
•Pulse rate : 87 beats per minute, regular rythm,normal volume and character of vessel,no radio-radial delay and no radio- femoral delay.
• Respiratory Rate: 20 cycles per minute.
• Blood pressure: 130/80 mm hg.
• Temperature: afebrile.
• spo2 : 97%
• grbs : 201mg/dl.
SYSTEMIC EXAMINATION
ABDOMINAL EXAMINATION
•INSPECTION:
Abdomen distended.
Umbilicus normal in shape and position.
No scars and sinuses visible.
No dilated veins and no visible gastric peristalsis.
• PALPATION:
No local rise of temperature
No tenderness
Organs were not palpable.
• PERCUSSION:
Fluid Thrill present
• AUSCULTATION:
Normal bowel sounds heard.
• RESPIRATORY EXAMINATION:
Examination of upper respiratory tract normal
Examination of Lower respiratory tract:
INSPECTION:
Trachea is central in position.
Chest is Symmetrical.
Movement - bilaterally equally.
Thoracoabdominal type of breathing.
No use of accessory muscles.
PALPATION:
Trachea central in position.
Chest expanding symmetrically.
Vocal fremitus decreased in inframammary, infra axillary and infra scapular area on both sides.
PERCUSSION:
Stony dull note in inframammary,infra axillary and infra scapular areas.
AUSCULTATION:
Decreased breath sounds in inframammary, infra axillary and infra scapular areas of chest.
Normal vesicular breath sounds.
CARDIOVASCULAR SYSTEM
S1 S2 Heard.
CNS EXAMINATION
No neurological deficit.
INVESTIGATIONS:
ON 10-6-22:
Hemogram:
Hb;6.5gm/dl
RBC count:2.42millions /cumm
TLC:7100cells/cumm
Neutrophils;70%
lymphocytes;17%
MCV:80.2fl
MCH:26.9pg
MCHC;33.5%
RDW-cv;14.2%
Platelet count:1.20lakhs/cumm
Smear:normocytic and normochromic
Blood urea- 110mg/dl.
Serum creatinine- 6.2 mg/dl.
Serum electrolyte:
Na-136 mEq/l.
K- 3.5 mEq/l.
Cl- 97mEq/l.
SEROLOGY:
HBsAG-negative.
Anti hcv antibodies- Non reactive
HIV RAPID TEST - Non reactive.
USG REPORT FINDINGS:
B/l grade 2 rpd.
Gross ascites.
B/l moderate to gross Pleural Effusion.
CHEST X RAY:
INVESTIGATION ON 11-6-22:
Hemogram:
Blood urea- 127 mg/dl
Serum creatinine- 6.7 mg/dl.
Serum electrolytes:
Na - 136 mEq/l.
K - 3.5 mEq/l.
Cl - 97mEq/l.
PROVISIONAL DIAGNOSIS:
Chronic kidney disease on maintainance hemodialysis with bilateral pleural effusion.
TREATMENT:
On 10-6-22:
Inj. Lasix 60mg/IV/BD.
Inj .human actrapid insulin.6U/iv/stat
Insulin infusion 6ml/hr
Tab.nicradia 20 mg /po/BD
Tab .Telma 40 mg/po/OD
NBM till further orders
Fluid and salt restriction
Grbs monitoring hrly .
On 11-6-22
Inj. lasix 60 mg /iv/BD
Inj insulin infusion 6ml/hr
Tab.nicardia 20 mg/po/bd
Tab. Telma 40 mg/po/oD
NBM till further orders
Fluid and salt restriction.
Grbs monitoring hlry
On 12-6-22
Inj.lasix 60 mg/iv/BD
Inj .human actrapid S/c
Tab.nicardia 20 mg /PO/BD
Tab.Telma 40 mg/PO/oD
Fluid and salt restriction
Bp/PR/Grbs 4th hourly
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