61 year old female with Bilateral pedal edema since 6 months
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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.
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
