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A 56 year old female patient, resident of Raselpuram who is farmer by occupation came to hospital with Chief complaints of
Shortness of breath since 2 months
Swelling of legs since 2 months.
She previously went to a hospital in Nalgonda 5 yrs back with complaints of severe back pain radiating to lower abdomen and groin,fever and burning micturation and was diagnosed as Renal stones.
After 1 yr she again visited the hospital for followup checkup then was diagnosed as Chronic Kidney disease for which she was on medical treatment for 4 yrs and now on MHD since 3 months.
Now she presented with complaints of :
Shortness of breath since 2 months
Swelling of legs since 2 months
Shortness of breath was insidious in onset, gradually progressive from grade 2 to grade 3(NYHA grading). Aggrevated on walking and while performing daily activities. Worsens at night and on lying down(Orthopnea), releived on medications initially but later on it is not releived by medications also.
H/o reduced urine output.
No h/o fever, chills, cough, hemoptysis, sputum production,
No h/o chest pain, palpitations, syncope
No h/o abdominal pain, abdominal distension ,nausea, vomiting, and diarrhea.
Past history:
K/c/o Hypertension since 7 yrs ( visited to the hospital with complaints of headache and neck pain) - on medication (Telmisartan ;used medication irregularly)
No h/o DM ,Thyroid disorders, Asthma, Epilepsy,TB, coronary artery disorders
Menstrual history:
Age of menarche :13 years, regular cycles 5/30
Menopause attained at 50 years
Family history: Not relevant
Personal history:
Diet:Mixed
Appetite: Decreased
Sleep: Decreased
Bowel: Regular
Bladder: Decrease urine output
No addictions
Drug history:
NSAIDS (diclofenac) used for renal pain
Medications to control hypertension - telmisartan(80mg)
No known drug allergies
General examination:- (consent obtained)
The patient is conscious, coherent, cooperative , well built and well nourished. Well oriented to time,place and person.
Pallor-present
Clubbing- absent
Cyanosis- absent
Koilonychia- absent
Lymphadenopathy- absent
Pedal edema- bilateral grade 2 pitting type
Vitals-
Temperature- Afebrile
BP- 110/70 mm Hg right arm in supine position
PR- 88 bpm, regular rhythm
RR- 20 cpm thoraco-abdominal.
SpO2:- 94% at room temperature.
SYSTEMIC EXAMINATION:
Respiratory examination:
Upper respiratory system-
Oral cavity- normal
Nose- normal
Pharynx- normal
Lower Respiratory Tract:
Inspection:
Trachea: central
Shape of chest: Elliptical
Symmetry of chest : symmetrical
Movement: B/L symmetrical expansion of chest during respiration
Apex beat- left 5th ICS medial to MCL
No scars, engorged veins or sinuses.
Palpation:
All inspectory findings are confirmed by palpation.
Trachea: central - (confirmed by three finger test.)
Assessment of anterior and posterior chest expansion- B/L symmetrical expansion of chest.
No chest wall tenderness
Vocal fremitus- normal
Percussion :
Right Left
SCA Resonant Resonant
ICA Resonant Resonant
Mammary Resonant Resonant
IMA Resonant Resonant
Axillary Resonant Resonant
IAA Resonant Resonant
Suprascapular Resonant Resonant Interscapular Resonant Resonant
Infrascapular Resonant Resonant
Auscultation :
Basal crakles are heard on both sides
Right Left
SCA NVBS NVBS
ICA NVBS NVBS
Mammary NVBS NVBS
IMA NVBS NVBS
Axillary NVBS NVBS
IAA NVBS NVBS
Suprascapular NVBS NVBS
Interscapular NVBS NVBS
Infrascapular NVBS NVBS
Vocal resonance - normal
Cardiovascular System :
Inspection :
No scars sinuses and engorged veins.
No visible pulsations
Palpation:
apical impulse : felt in fifth inter coastal space
Auscultation:
S1 and S2 heard
No murmurs
Per Abdomen:
Inspection:
Shape : elliptical
Quadrants of abdomen moving in accordance with respiration.
Umbilicus- central and inverted
No scars sinuses or engorged veins
Palpation:
No tenderness
No organomegaly
Percussion :
tympanic
Auscultation:
Normal bowel sounds heard
CNS:
Higher mental functions-normal
Cranial nerves- intact
Sensory system- normal
Motor system- normal
Meningeal signs- absent
Cerebellar signs- absent
INVESTIGATIONS:
CBP - reduced Hb
CUE - albumin in urine
LFT -
raised ALP
reduced total protein
reduced albumin
RFT -
raised urea
raised cretinine
raised uric acid and calcium
CXR -
Mild cardiomegaly
Perihilar hazziness
Air bronchogram appearance
Ground glass opacities and interstitial
opacities
USG -
Right kidney Grade 2 RPD
Left kidney Grade 1 RPD
PROVISIONAL DIAGNOSIS :
Chronic kidney disease on Maintenance Hemodialysis with Pulmonary edema
TREATMENT:
Tab.LASIX 40mg BD
Tab.PAN 40mg OD
Tab.NODOSIS 500mg BD
Tab. OROFER XT OD
Inj.Erythropoietin 4000 IU/SC
BP,PR,Spo2 -monitoring
Salt and fluid restriction
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