65 year old female came to Medicine OPD on 15.11.2021

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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