57 year old female with DECREASED URINE OUTPUT

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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 

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