56 YR OLD FEMALE WITH DECREASED URINE OUTPUT, SOB, GENERALIZED BODY SWELLING

202420840 kotamma
CASE HISTORY AND CLINICAL FINDINGS
PATIENT CAME WITH COMPLAINTS OF DECREASED URINE OUTPUT SINCE 5-6 DAYS
C/O SHORTNESS OF BREATH SINCE 10 DAYS
C/O GENERALISED BODY SWELLING SINCE 2-3 MONTHS
PATIENT WAS APPARENTLY 2-3 MONTHS AGO, THEN SHE DEVELOPED GENERALISED
BODY SWELLING (ANASARCA) WITH FACIAL PUFFINESS AND BILATERAL PEDAL EDEMA.
H/O SHORTNESS OF BREATH, GRADE III MMRC, A/W PROFUSE SWEATING. H/O DECREASED
URINE OUTPUT SINCE 5-6 DAYS (OLIGURIA), ABOUT <250ML/DAY, A/W BURNING
MICTURITION (DURING VOIDING OF URINE). H/O VOMITING FOR 5-6 DAYS, 1-2 EPISODES/
DAYS, MORE DURING MORNING. H/O DECREASED APPETITE.
NO H/O LOOSE STOOLS, SEIZURES, LOSS OF CONSCIOUSNESS, HEADACHE, COUGH,
COLD, FEVER, PAIN ABDOMEN.
K/C/O TYPE 2 DM SINCE 5-6 YEARS ON TAB. METFORMIN 500MG OD
K/C/O HTN SINCE 2 YEARS ON TAB. METXL 25MG OD IRREGULARLY
K/C/O CKD SINCE 2 1/2 - 3 YEARS ON TAB. LASIX 40MG OD AND T. NODOSIS 500MG
TREATMENT HISTORY:
T. METFORMIN 500MG OD SINCE 5 YEARS
T. METXL 25MG OD ON IRREGULAR BASIS SINCE 2 YEARS
T. LASIX 40MG, T. NODOSIS 500MG SINCE 2 1/2 YEARS
PERSONAL HISTORY:
MARRIED
DECREASED APPETITE
MIXED DIET
CONSTIPATION
DECREASED URINARY OUTPUT
NO ADDICTIONS
GENERAL EXAMINATION:
PATIENT IS CONSCIOUS, COHERENT AND COOPERATIVE. MODERATELY BUILT AND WELL
NOURISHED
BP- 150/80 MM HG
PR- 96 BPM
RR- 18 CPM
SPO2- 99%
TEMP- AFEBRILE
PALLOR +
EDEMA+
ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY
SYSTEMIC EXAMINATION:
CVS- S1, S2 HEARD
RS- NO DYSPNOEA, NO WHEEZE, CENTRAL POSITION OF TRACHEA, BILATERAL AIRWAY
PRESENT, NORMAL VESICULAR BREATH SOUNDS HEARD, NO ADVENTITIOUS SOUNDS
HEARD
CNS- NO FOCAL DEFICITS
P/A- SOFT, NON-TENDER
DIALYSIS DONE ON
14/5/24
15/4/24
17/4/24
18/5/24
INVESTIGATION
NameValueNameValueAnti HCV Antibodies - RAPID12-05-2024 05:26:PMNon Reactive HBsAg-
RAPID12-05-2024 05:26:PMNegative RFT 12-05-2024 05:26:PMUREA114 mg/dlCREATININE12.0
mg/dlURIC ACID8.0 mmol/LCALCIUM8.0 mg/dlPHOSPHOROUS8.4 mg/dlSODIUM138
mmol/LPOTASSIUM5.0 mmol/L.CHLORIDE106 mmol/LABG 12-05-2024
05:26:PMPH7.094PCO216.7PO295.9HCO34.9St.HCO37.3BEB-23.4BEecf-23.2TCO211.3O2
Sat96.1O2 Count9.8LIVER FUNCTION TEST (LFT) 12-05-2024 08:58:PMTotal Bilurubin1.15
mg/dlDirect Bilurubin0.15 mg/dlSGOT(AST)16 IU/LSGPT(ALT)12 IU/LALKALINE
PHOSPHATASE166 IU/LTOTAL PROTEINS5.0 gm/dlALBUMIN3.0 gm/dlA/G RATIO1.0COMPLETE
URINE EXAMINATION (CUE) 12-05-2024
08:58:PMCOLOURReddishAPPEARANCECloudyREACTIONAcidicSP.GRAVITY1.010ALBUMIN+++
+SUGARNilBILE SALTSNilBILE PIGMENTSNilPUS CELLSplentyEPITHELIAL CELLS3-4RED
BLOOD CELLSplentyCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilRFT 12-
05-2024 11:40:PMUREA115 mg/dlCREATININE12.5 mg/dlURIC ACID8.0 mmol/LCALCIUM8.4
mg/dlPHOSPHOROUS8.8 mg/dlSODIUM139 mmol/LPOTASSIUM4.9 mmol/L.CHLORIDE106
mmol/LRFT 15-05-2024 06:34:AMUREA130 mg/dlCREATININE14.5 mg/dlURIC ACID8.0
mmol/LCALCIUM8.3 mg/dlPHOSPHOROUS8.2 mg/dlSODIUM141 mmol/LPOTASSIUM4.5
mmol/L.CHLORIDE106 mmol/LRFT 15-05-2024 08:55:PMUREA96 mg/dlCREATININE11.0
mg/dlURIC ACID5.6 mmol/LCALCIUM8.7 mg/dlPHOSPHOROUS6.0 mg/dlSODIUM138
mmol/LPOTASSIUM4.1 mmol/L.CHLORIDE103 mmol/LCOMPLETE BLOOD PICTURE (CBP) 15-05-
2024 08:55:PMHAEMOGLOBIN8.2 gm/dlTOTAL COUNT12000 cells/cummNEUTROPHILS80
%LYMPHOCYTES15 %EOSINOPHILS03 %MONOCYTES02 %BASOPHILS00 %PLATELET
COUNT1.5SMEARNormocytic normochromic anemia with leukocytosisBLOOD UREA16-05-2024
07:21:AM103 mg/dlSERUM CREATININE16-05-2024 07:21:AM11.0 mg/dl
USG ABDOMEN -
B/L GRADE 1 RPD CHANGES , MODERATE ASCITES
DIAGNOSIS
CHRONIC KIDNEY DISEASE
K/C/O DM 2,HTN
TREATMENT GIVEN
SALT RESTRICTION <2G/DAY
FLUID RESTRICTION <1.5 L/DAY
INJ. LASIX 69MG IV/BD
INJ. ZOFER 1MG IV/TID
INJ. MONOCEF 1G IV/BD
INJ. PAN 40MG IV/OD
TAB. SODA BICARBONATE 100MG PO/BD
TAB. NODOSIS 500MG PO/BD
TAB. SHELCAL PO/OD
TAB. ULTRACET PO/SOS
TAB. OROFER- XI PO/OD
ADVICE AT DISCHARGE
SALT RESTRICTION <2G/DAY
FLUID RESTRICTION <1.5 L/DAY
INJ ERYTHROPIETIN 4000 IU SC/ONCE WEEKLY
TAB. NODOSIS 500MG PO/BD
TAB. SHELCAL-CT PO/OD
TAB. OROFER- XT PO/OD
TAB NICARDIA 20 MG PO BD
TAB METXL 25MG PO OD AT 2PM
TAB LASIX 40 MG PO BD
TAB PAN 40 PO OD 8AM BEFORE FOOD FOR 1 WEEK

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