53 yr old female with pedal oedema and shortness of breath
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53 yr old female patient came to opd with Chief complaints of
- Shortness of breath since 3 days ,pedal oedema since 4 days.
History of presenting illness:
Patient was apparently asymptomatic , noticeable events as -12 yr back she had high grade fever then she visited govt hospital,she was treated and then 4yr back she was diagnosed with hypertension on symptoms of chronic neck pain ,giddiness , headache and medicated to it.
10 months back she developed shortness of breath ,she visited the hospital ,investigations revealed blood urea and creatinine levels being raised .
She was diagnosed with renal failure ,undergoing dialysis weekly twice along blood transfusion
She has noticeable shortness of breath ,pedal oedema 4 days back.
Her pedal oedema is resolved .
Past history:
History of hypertension since 4 yrs.
NO H/O DM, ASTHMA , TB, EPILEPSY.
Personal history:
Appetite - normal
Diet - mixed
Bowel movements - regular
Bladder - Decrease urinary output
No addiction
Family history:
No significant family history
General examination:-
Patient was consious,coherent,and cooperative,well oriented with time ,plac e,person.
Pallor - present
Icterus - absent
Clubbing - absent
Cyanosis - absent
Lymphadenopathy - absent
Oedema - bilateral pedal oedema which is pitting type and grade 2
Oedema subsided later.
Temperature 98.7°F
Blood pressure: 140/90
Respiratory rate :20
Pulse rate :90
Sp02:98%
Systemic examination;
CVS
Normal s1 and s2 sounds heard
No cardiac murmurs
RESPIRATORY SYSTEM
Normal vesicular breath sounds heard
Respiratory crepts present on right
P/A
Soft, non tender, bowel sounds- normal
CNS
no focal neural defecits, GCS - 15/15, no signs meningeal irritation, motor system normal.
Investigations
Hemogram
On 30/1
LFT
RFT
2D echo findings
Dilated RA,RV ,LA,concentric LVH +
Anterior wall hypokinetic,RWMA +
Ultra sound findings:
Moderate pleural effusion with collapsed underlying lung segment.{right}
Mild pleural effusion {left}
Mild pericardial effusion
Bilateral renal pelvic dilatation.
Provisional diagnosis
Chronic kidney disease on Maintenance hemodialysis.
Treatment:
On 31 /1
Tab lasix 40mg TID
Tab nicardia 10mg TID
Tab arkamine 0.1mg QID
Tab met-xl 50mg BD
Tab nodosis 500mg BD
On 1/2/22
Tab lasix 40mg TID
Tab nicardia 10mg TID
Tab arkamine 0.1mg QID
Tab met-xl 50mg BD
Tab nodosis 500mg BD
Tab order xl 0d
Tab shelcal 500mg OD
On 2/2
Tab lasix 40mg TID
Tab nicardia 10mg TID
Tab arkamine 0.1mg QID
Tab met-xl 50mg BD
Tab nodosis 500mg BD
Tab order xl 0d
Tab shelcal 500mg OD
Patient is advised on dialysis weekly twice.
