57 year old female with DECREASED URINE OUTPUT

-
57 YEAR FEMALE WITH DECREASED URINE OUTPUT AND SHORTNESS OF BREATH 

COMPLAINTS :

A 57 year old female patient presented to the OPD with chief complaints of decreased urine output since 3 days and shortness of breath grade II-III since one day And fever not associated with chills and rigors 


HISTORY OF PRESENT ILLNESS :

57 year old female patient resident of sirikonda,, housewife . She was apparently asymptomatic 3 years back then she had low back pain which was radiating to groin diagnosed as renal caliculi managed conservatively.... f/b diagnosed with CKD managed conservatively 

*Decreased urine output since 3days 
*Sob grade II-III since yesterday night
*Cough with sputum yellowish in colour intermittent f/b blood tinged sputum 
*And fever not associated with chills and rigors 

PAST HISTORY:

No similar complaints in the past

 MEDICAL HISTORY:

Not a know case of diabetes, hypertension, tuberculosis, epilepsy, asthma.

FAMILY HISTORY:

No relevant family history

PERSONAL HISTORY:

-Mixed diet
-REDUCED APPETITE
-Adequate sleep
-Regular bowel movements
-MICTURATION: Pt HAS DECREASED URINE OUTPUT.

GENERAL PHYSICAL EXAMINATION:

PALLOR - Present 
Icterus - Absent
Cyanosis - Absent
Clubbing - Absent
Lymphadenopathy - Absent
Pedal oedema - PRESENT ( PITTING TYPE) 

Vitals:
Temperature- afebrile
Pulse rate- 89 beats per minute
Respiratory rate- 22 breaths per minute
B.P- 110/70 mm hg
SpO2- 90% at room air

SYSTEMIC EXAMINATION:

Cardiovascular system- s1 and S2 are heard no murmurs are heard

Respiratory system:
Dyspnoea- present
Breath sounds- decreased breath sounds in right 
Vesicular breath sounds are normal
Wheezing- present

Rt side Fine Crepts present 
BAE- positive

Central nervous system- Patient was conscious coherent and cooperative.
Speech was normal.
No slurred speech
No meningeal irritation signs 

-No abnormality detected.

REFLEXES

Right and left biceps triceps supinator ankle and knee show grade 2 Reflex

GAIT - Normal 

                      INVESTIGATIONS:


      X-RAY:

 

Usg report :


                 LAB INVESTIGATIONS:

 

                          ECG:
 

         
 

PROVISIONAL DIAGNOSIS:

CKD with right sided pleural effusion


   PLEURAL TAP was done 


SR LDH --255IU/DL 
PLEURAL LDH--1968IU/DL 
SR PROTEINS 5.4 G/DL 
PL PROTEIN 3.6 G/DL 
PL SUGAR 71 MG/DL



Spot urine protein 53mg/dl 
Spot urine creatine 106mg/dl 
Ratio 0.50 
Sr Electrolytes 
Na+ 135 meq/l
K+ 4.0meq/l 
Cl- 92meq/l

Creatine clearence 11ml/min 

Hemogram 
HB 8.6 
TLC 29000
Plt 2.57
N 96
L 1
Pcv 24.9 
MCV 72.5 
Mchc 34.7 

18/12/21 :

One session of dialysis done 




19/12/21 :

 Soap notes amc bed 3
 
S-
  shortness of breath - reduced
  No fever spikes

O: 
O/e pt c/c/c 
Temp afebrile
Bp 90/60 mmHg
 pr 112bpm  
 Spo2 92% @ 4 RA
 Cvs s1s2heard no murmurs
 Rs : 
 BAE +
 TRACHEA CENTRAL 
 VESICULAR BREATH SOUNDS HEARD 
 Decreased breath sounds in Right Infrascapular and suprascapular area.
 Crepts present on right infrascapular area.
P/A 
soft non tender 
Distended
Bowel sounds heard 

CNS :NAD 
 HB: 8.1, TLC: 23,000, PLT: 2.33, N - 85, L - 0.5, UREA: 137, CREAT: 4.6, NA+- 138, K- 3.8, CL- 94

A-
CKD with rt sided pleural effusion ( EXUDATIVE)

P:-

1. Head and elevation up to 30°
2. O2 supplementation if SpO2 is less than 90%.
3.  Fluid restriction < 1 litre per day
4.  Salt restriction < 2.4 G per day
5..inj piptaz 2.24gm iv/bd 
7.  Inj. Lasix 40 mg IV/ BD
8.  Tab. Nodosis 550mg PO/BD
9.  Tab shelcal 500 mg PO/OD
10. Tab orofer-xT /OD
11.  Inj. Erythropoietin 4000 IU s/c weekly once
12. .Inj. Iron sucrose 1Amp in 100 ml us during dialysis
13. .Syrup. Ascoryl 10ml /TID
14. . Neb with salbutamol thrice daily




 

20/12/21 :

 Soap notes amc bed 3
 
S-
  shortness of breath - reduced
  No fever spikes
Stools passed 

O: 
O/e pt c/c/c 
Temp afebrile
Bp 100/70 mmHg
 pr 98bpm  
 Spo2 95%@RA

I/O 500/750ML 

 Cvs s1s2heard no murmurs
 Rs : 
 BAE +
 TRACHEA CENTRAL 
 VESICULAR BREATH SOUNDS HEARD 
 Decreased breath sounds in Right Infrascapular and suprascapular area.
 Crepts present on right infrascapular area.
P/A 
soft non tender 
Distended
Bowel sounds heard 

CNS :NAD 

A-
CKD with rt sided pleural effusion ( EXUDATIVE)

P:-

1. Head and elevation up to 30°
2.  O2 supplementation if SpO2 is less than 90%.
3.  Fluid restriction < 1 litre per day
4.  Salt restriction < 2.4 G per day
5. D3 inj piptaz 2.25 gm/ IV/ BD
7.  Inj. Lasix 40 mg IV/ BD
8.  Tab. Nodosis 550mg PO/BD
9.  Tab shelcal 500 mg PO/OD
10.  Tab orofer-xT /OD
11.  Inj. Erythropoietin 4000 IU s/c weekly once
12. .Inj. Iron sucrose 1Amp in 100 ml us during dialysis
13. Syrup. Ascoryl 10ml /TID
14.  Neb with salbutamol thrice daily 
15 SYP LACTULOSE 10ML PO/BD
PLAN FOR DIALYSIS


20/12/21:

Rft 
Urea 160 mg/dl 
Creatinine 4.3mg/dl 
Uric acid 6.1mg/dl 
Phosphorus 3.8mg/dl 
Calcium 9.1meq/l
Sodium 143meq/l
Potassium 3.8meq/dl 
Chloride 96meq/dl 


Serum Albumin 2.7g/dl 
Serum iron 80ug/dl 



Shifted to CKD ward from amc bed 3 

21/12/21: 

 SOAP NOTES
S-
  shortness of breath - reduced , no fresh complaints 
  No fever spikes
Stools not passed
 
O: 
O/e pt c/c/c 
Temp afebrile
Bp 100/70 mmHg
 pr 98bpm  
 Spo2 96%@RA

 Cvs s1s2heard no murmurs
 Rs : 
 BAE +
 TRACHEA CENTRAL 
 VESICULAR BREATH SOUNDS HEARD 
 Decreased breath sounds in Right Infrascapular and suprascapular area.
 Crepts present on right infrascapular area.
P/A 
soft non tender 
Distended
Bowel sounds heard 

CNS :NAD 


A-
CKD with rt sided pleural effusion ( EXUDATIVE)

P:-

1. Head and elevation up to 30°
2.  O2 supplementation if SpO2 is less than 90%.
3.  Fluid restriction < 1 litre per day
4.  Salt restriction < 2.4 G per day
5. D4 inj piptaz 2.25 gm/ IV/ BD
7.  Inj. Lasix 40 mg IV/ BD
8.  Tab. Nodosis 550mg PO/BD
9.  Tab shelcal 500 mg PO/OD
10.  Tab orofer-xT /OD
11.  Inj. Erythropoietin 4000 IU s/c weekly once
12. Inj. Iron sucrose 1Amp in 100 ml us during dialysis
13. Syrup. Ascoryl 10ml /TID
14.  Neb with salbutamol thrice daily 
15 SYP LACTULOSE 10ML PO/BD
 UNDERGOING DIALYSIS
 

 CKD ward 

22/12/21 :

 SOAP NOTES

S -
Pedal Edema Present 
  shortness of breath - reduced , 
  No fever spikes
Stools passed 

O: 
O/e pt c/c/c 
Temp afebrile
Bp 110/70 mmHg
 pr 98bpm  
 Spo2 96%@RA

 Cvs s1s2heard no murmurs
 Rs : 
 BAE +
 TRACHEA CENTRAL 
 VESICULAR BREATH SOUNDS HEARD 
 Decreased breath sounds in Right Infrascapular and suprascapular area.
 Crepts present on right infrascapular area.
P/A 
soft non tender 
Distended
Bowel sounds heard 

CNS :NAD 

A-
CKD with rt sided pleural effusion ( EXUDATIVE)

Underwent 2 sessions of dialysis on 18/12/21 and 21/12/21  

P:-

1. Head and elevation up to 30°
2.  O2 supplementation if SpO2 is less than 90%.
3.  Fluid restriction < 1 litre per day
4.  Salt restriction < 2.4 G per day
5. D5 inj piptaz 2.25 gm/ IV/ BD
7.  Inj. Lasix 40 mg IV/ BD
8.  Tab. Nodosis 550mg PO/BD
9.  Tab shelcal 500 mg PO/OD
10.  Tab orofer-xT /OD
11.  Inj. Erythropoietin 4000 IU s/c weekly once
12. Inj. Iron sucrose 1Amp in 100 ml us during dialysis
13. Syrup. Ascoryl 10ml /TID
14.  Neb with salbutamol thrice daily 
15 SYP LACTULOSE 10ML PO/BD 

Comments

Post a Comment

Popular posts from this blog

30f with osteomalacia??

-
Image
A 30yr Old Female with ? Osteomalacia This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan CASE A 30yr old female, Daily wage Labourer by occupation came to OPD with cheif complaints of Pain in B/L Lower limbs since 2 years.  Patient wa
Read more

83 MOHAMMED WAHAAJ BIMONTHLY ASSIGNMENT

-
 BIMONTHLY  ASSIGNMENT (August)   BELOW IS THE LINK TO THE QUESTIONS ASKED TO US:- http://medicinedepartment.blogspot.com/2021/08/medicine-paper-for-aug-2021-bimonthly.html QUESTION 1:- Below is the link of the student for which I am giving my peer review. https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006003-case-presentations.html?m=1 LONG CASE  :- A 44 year old man presented with a 3-day history of bilaterally symmetrical rapidly progressive generalized edema. REVIEW:- The Case is well presented and  p atient data has be deidentified and privacy is marked. C ase history is taken beautifully precisely taken including social ,educational and surgical  history which is way too essential to understand the socio economic back ground of the patient and helpful in accurate diagnosis. FINAL DIAGNOSIS : - Acute Glomerulonephritis, likely due to Secondary Amyloidosis due to Chronic Poorly Treated Seronegative Erosive Rheumatoid Arthritis. Dilutional Hyponatremia secondary to A
Read more

RIGHT HEART FAILURE SECONDARY TO COPD

-
Image
  under the guidance of Dr. Rishik (Intern) This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission. I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including, history, clinical findings, investigations, and come up with a diagnosis and treatment plan. CASE SCENARIO: A 52yr old patient came to the ward on 29 June 2021 with chief complaints of  right lower limb swelling, intermittent fever (alive and well), shortness of breath  since 3days, and  burning micturition  for 15 days. HISTORY OF PRESENTING ILLNESS The patient was asymptomatic 5days ago, after which he developed right lower limb swelling up to the knee. No H/O trauma, thorn prick, nausea, vomiting c/o a small wound, watery discharge since 2 days Fever- 5days intermittent, low grade, a/w chill A light rise in temp sob on exertion -5days a/w cough- 1
Read more