61 year old female with Bilateral pedal edema since 6 months

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. 

CASE PRESENTATION:

A 61 year old female who is a farmer by occupation came with complaints of-

 Pedal edema followed by  facial puffiness since 1 week

Loss of appetite since 10 days  

Shortness of breath since 2 days.

Patient was apparently asymptomatic 6 months back,  then she developed per vaginal bleeding which is insidious in onset, she is bleeding continuously for 3 months, which is foul smelling , relieved on it's own. No h/o clots, dysmenorrhea.

Then she developed generalized weakness which was insidious in onset, non- progressive in nature. She is unable to do her daily routine activities (cooking,  washing), then she went to local RMP where he gave her medications( records not available).

         After 2 days she developed pain in loin and burning micturation which is insidious in onset, non- progressive in nature, dragging type of pain , non - radiating, aggrevated while doing work and  walking, on and off type. Relieved on medication ( records not available)

      After 1 day she developed shortness of breath which aggrevated on doing work and walking ..she went to private hospital where her serum creatinine level was 7.4. Medications were given( Tab. Nexovas 10mg , Tab. Nodosis, Tab.Monocef) .Then referred to hyderabad hospital in view of dialysis but patient refused to go there due to lack of money .

She came to Kims for further evaluation.

Her 1st dialysis done on 7/10/20 .

2nd dialysis was done on 10/10/20

3rd dialysis was done on 11/10/20

During her dialysis she was stable before and after dialysis.

Past history:- Not a known case of DM, HTN, CAD, CVA, TB, Asthma
No h/o any previous  blood transfusions  and surgeries.

FAMILY HISTORY :No H/O similar complaints in the family

PERSONAL HISTORY:

 He was on mixed diet, appetite normal, bowel and bladder habits regular and no addictions .

GENERAL EXAMINATION: 

 pt is conscious, coherent, cooperative and oriented to time, place and person  

Pallor present

no Icterus,cyanosis,clubbing, lymphadenopathy,edema

VITALS:

Temperature-99.8°f on presentation 

BP:130/90mmhg

PULSE:82bpm

RR:19cpm

Spo2:98%

GRBS:98mg/dl

Systemic examination:-

CVS- s1 s2 heard,no murmurs

RESPIRATORY SYSTEM -bilateral air entry present , + normal vesicular breath sounds. no added sounds

PER ABDOMEN-

       Scaphoid in shape,no tenderness and no palpable mass present.Hernial orifices are free.Liver and spleen are not palpable.Bowel sounds are present.

CNS:

all higher motor functions are normal

Cranial nerves intact

Sensory system normal

Motor system normal

Cerebellar signs normal

No meningeal signs

Investigations:-


Diagnosis- Acute kidney injury with obstructive uropathy


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