67/F with SOB & decreased urine output
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Case history:
A 67 year old female resident of came with the complaints of SOB since yesterday night.
History of present illness:
Patient was apparently asymptomatic 2 years back. She had complaints of decreased urine output, B/L pedal edema, SOB and facial puffiness for 1 month. She also developed altered sensorium for 2 days for which she was taken to a local hospital and was diagnosed with renal failure with heart failure. She was on conservative management. Later, (due to recurrent symptoms) She had undergone 2 dialysis and a blood transfusion due to low haemoglobin after her symptoms relieved. Then she came to KIMS, Narketpally for further dialysis as suggested by her Doctor.
She had pedal edema, altered sensorium and no urine output since past 3 days. Later she developed SOB (yesterday night)which gradually progressed to the state she was brought in. Aggravated on lying down and slightly relieved in sitting.
Past history:
▪ Known case of DM since 25years.
K/c/o HTN since 20years. On regular medication for both DM, HTN.
▪ No history of CVA, asthma, epilepsy, CAD.
Family history
Not significant
Personal history
* Diet- mixed.
* Appetite- normal
* Sleep- adequate
* bladder movements - decreased
* Bowel movements- regular
* No addictions
* General examination:
Patient was conscious , coherent, cooperative well oriented to time , place person
Pallor- mild
icterus- absent
cyanosis- absent
clubbing- absent
Lymphadenopathy - absent
Edema- B/L pedal edema present.
Vitals:
Temp: 98.6 F
BP: 170/60 mm Hg
PR: 104 bpm
Spo2: 100% @ O2 6L
Systemic examination;
RESPIRATORY SYSTEM-
Inspection-
Chest is bilaterally symmetrical
The trachea is positioned centrally
Apical impulse is not appreciated
Chest moves normally with respiration
No dilated veins, scars or sinuses are seen
Palpation-
Trachea is felt in the midline
Chest moves equally on both sides
Apical impulse is felt in the sixth intercostal space
Tactile vocal fremitus- appreciated
Percussion-
The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.
They are all resonant.
Auscultation-
Normal vesicular breath sounds are heard.
(Presented with adventitious sounds in RT ISA)
Per Abdomen
Inspection:
Skin - regular, normal.
Shape - distended
Umbilicus - normal
Abdominal wall movements - present
No visible pulsations and peristaltic movements seen.
Palpation:
Tenderness - mild
No rise of temperature
Liver - not palpable
Spleen - mild palpable
Gall bladder - not palpable
Kidneys - not palpable
Percussion:
Liver - dull note
Spleen - dull note
No shifting dullness, fluid thrill.
Auscultation:
Bowel sounds heard.
No bruit.
CARDIOVASCULAR SYSTEM-
Inspection-
The chest wall is bilaterally symmetrical.
No dilated veins, scars or sinuses are seen
Apical impulse or pulsations can be appreciated in sixth intercostal space 2cms lateral to mid clavicular line
Palpation-
Apical impulse is felt in the sixth intercostal space, 2 cm away from the midclavicular line
No parasternal heave or thrills are felt
Percussion-
Right and left borders of the heart are percussed
Auscultation-
S1 and S2 heard, no added thrills and murmurs are heard
Central nervous system:
No abnormalities detected
Investigation:
On 15/3/23
RBS: 126mg/dl
Blood urea : 92mg/dl
Sr. Creatinine: 5.7mg/dl
Sr. Iron : 42ug/dl
Serology: negative
BGT : O +ve
Sr. Electrolytes :
Hemogram
CUE
USG as on 15/3/23:
RT kidney : 8×3.4 cm
Lt kidney : 7.7× 3.2 cm
Normal size and Increased echotexture.
B/L grade I RPD
ECG as on 15/3/23
ECG as on 7/4/23
Blood urea - 151mg/dl
Sr. Creatinine - 8.9mg/dl
Urine for ketone bodies - negative
Sr. Electrolytes
ABG
CUE
Hemogram
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