65 year old female came to Medicine OPD on 15.11.2021

This is an online E log book to discuss our patient's de-identified health data shared after taking her guardian's signed informed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centered online learning portfolio and your valuable comments on comment box is welcome.

CASE DISCUSSION:

A 65 year old female came to Medicine OP with chief complaints of 
+ Pedal edema since 3 months 
+ SOB since 1 week
+ Decreased urine output since 1 week
+ Fever since 4 days

History of Presenting Illness:

+ Patient was apparently asymptomatic 3 months ago when she suddenly developed Pedal Edema which was gradual in onset, slow in progression and associated with Shortness of Breath (SOB) on exertion with decreased Urine output.

+SOB then progressed to MMRC grade IV (i.e. SOB even while taking rest) 3 days back with no aggravating or relieving factors. 

+H/o decreased urine output since 1 week.

+H/o facial puffiness 4 days back.

+H/o Fever (Low grade), since 4 days which was gradual in onset, and non progressive, relieved with medications, no aggravating factors.   

+No history of vomiting,pain abdomen,loose stools,chest pain, palpitations.

Past history:

+ H/o Chronic Renal Failure 6 years back for which hemodialysis done 4 times 4 yrs back after which patient was asked to be under follow up

+ H/o HTN for which she was on anti hypertensive medication

+ No H/o DM, Bronchial Asthma


Personal history: 

+ Appetite: Normal

+ Diet: Mixed

+ Sleep: Disturbed (decreased)

+ Bladder and Bowel movements: Decreased urine output.

+ Addictions/Allergies: Tobacco chewing since 40 years


O/E:

General examination

+ Patient is conscious, coherent and cooperative

+ Pallor - Present 

+ Icterus: Absent

+ Clubbing: Absent

+ Cyanosis: Absent

+ Lymphadenopathy: Absent

+ Edema: Pedal Edema (Pitting type)

Vitals:

+Temp: Afebrile 

+PR: 70 bpm 

+RR: 15 cpm 

+BP: 110/70 mmhg


Systemic Examination:

Respiratory system:

+Chest is elliptical, bilaterally symmetrical

+Equally moving on both sides with respiration

+Apex beat is seen and felt at 5th intercoastal space 1 cm medial to mid clavicular line 

+Normal vesicular breath sounds Heard


Cardiovascular system:

+No thrills

+S1 and S2 heard no added sounds  

+No cardiac murmurs heard

Clinical images:








INVESTIGATIONS:

Hemogram:

+ Hb: 6.7 gm/dl

+ TLC: 7100 cells/cumm

+ Neutrophils: 82%

+ Lymphocytes: 10%

+ Eosinophils: 4%

+ Monocytes: 4%

+ Basophils: 0%

+ PLC: 2.26 lakhs/cumm

+ NORMOCYTIC NORMOCHROMIC ANEMIA WITH RELATIVE NEUTROPHILIA


RBS: 160 mg/dl


RFT:

+ Blood Urea: 112 mg/dl

+ Serum Creatinine: 5.1 mg/dl

+ Na: 136 mEq/L

+ K: 4.8 mEq/L

+ Cl: 96 mEq/L


ECG





USG Finding

+ Bilateral grade 2 RPD





Provisional diagnosis:

+This is a case of Chronic Kidney Disease(CKD) on Maintenance Hemodialysis(MHD)

+Know case of HTN

Treatment:

+ Supportive care is given and patient maintained on hemodialysis

+ Salt restriction < 2gm/day

+ Fluid restriction < 1.5 L/day


Presentation video link: https://youtu.be/zkVX2Sl21Js

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