A 48 year old female with swelling in both the lower limbs
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FINAL EXAMINATION LONG CASE REPORT:
Reg no :$1701006185
Batch -2017
CASE HISTORY :
A 48 year old female, daily wage labourer by occupation came to the OPD with the complaints of
Swelling in both the lower limbs since 10-12 days
Shortness of breath since 9 days
Loss of appetite since 9 days
HISTORY OF PRESENTING ILLNESS :
She was apparently asymptomatic 4 months ago when she developed weakness of limbs and easy fatiguability following stress due to her son's wedding
Weakness of limbs and easy fatiguability were insidious in onset progressed gradually
There was occasional headache and neck pains
She could not do her daily routine work because of fatigue and weakness for which she went to nearby RMP and was given some medication (unknown). There she was diagnosed with hypertension and is taking medication irregularly
She developed SOB 4 months ago insidiously
on exertion ( grade II )
It aggravated from grade 2 to grade 4 in the past 9 days with SOB at rest and while talking
She had SOB on lying down
Since 2 months she is also haeving decreased urine output . She urinates 2-3 times a day with total urine output of the day equal to a cup
She developed swelling in the lower limbs bilaterally 12 days ago which was insidious in onset and progressed gradually upto below knee in 3 days and remained like that until treatment at nalgonda hospital
It was pitting type of edema
She was admitted to a hospital in Nalgonda 10 days back for SOB ,fatiguability and decresed urine output where she was given blood transfusion for severe anemia and was told to have renal failure and she was discharged after 4 days and referred to our centre for dialysis
After blood transfusion her symptoms of SOB and fatiguability improved and edema is reduced
She had 3 episodes of vomitings and 3-4 episodes of loose stools after blood transfusion
She has a history of intermittent fever since past 4 months which subsided on medication
Her Daily routine changed because of weakness, fatiguability and SOB. She stopped going to work for months ago because of increasing dyspnea on working and easy fatiguability.
PAST HISTORY :
She doesn't have any comorbidities like diabetes, asthma, tuberculosis, epilepsy, thyroid disease
PERSONAL HISTORY:
mixed diet
Appetite is reduced since past 1 week
Sleep is adequate
Bowel movements - regular
Bladder - reduced frequency and volume of urine since past 2 months it returned back to normal after blood transfusion and treatment at nalgonda hospital
She used to smoke sutta for the past 35 years daily before defecation and stopped 3 years ago for eye surgery
No other addictions
No allergies
Surgical history :
Hysterectomised 23 years ago
Had eye surgery (cataract) 3 years ago in the right eye
FAMILY HISTORY : insignificant
GENERAL EXAMINATION :
Patient is examined after taking informed consent in a well lit room
Patient is conscious,coherent,cooperative, well oriented to time, place and person and moderately built and moderately nourished
Pallor is present
Edema - present at the time of admission upto ankle,pitting edema. It reduced after treatment
No signs of Icterus, cyanosis, clubbing, lymphadenopathy
VITALS AT THE TIME OF ADMISSION :
Pulse rate : 80 bpm, regular rhythm, normal volume ,normal vessel wall, no radio-radial delay, no radio-femoral delay
Temp: 98.6F
BP:130/70 mmHg
RR: 18 cpm
GRBS: 103 mg/dL
SpO2: 98% on RA
CVS EXAMINATION :
S1, S2 heard
No murmurs, no muffled heart sounds
RESPIRATORY SYSTEM EXAMINATION :
Inspection :
Chest is elliptical
No visible scars, sinuses, pulsations
Bilaterally symmetrical
Palpation :
Bilateral air entry present
Percussion :
Resonant over all areas of chest
Auscultation :
normal vesicular breath sounds heard
No crepitus at the time of presentation
CNS EXAMINATION :
Normal, no abnormality detected
PERABDOMEN EXAMINATION :
abdomen is flat, scaphoid
Soft on palpation and non tender
INVESTIGATIONS :
On 11/06/22
On 13/06/22
ECG:
DIAGNOSIS : CHRONIC RENAL FAILURE WITH SEVERE ANEMIA
TREATMENT:
1)TAB LASIX 40MG PO/BD
2)TAB OROFER -XT PO/OD
3)TAB NODOSIS 50MG /BD
4)TAB PAN 40MG PO/OD
5)TAB SHELCAL 500MG PO/OD
6)TAB MVT PO/OD
7)INJ EPO 4000U S/C WEEKLY ONCE
8)SALT AND FLUID RESTRICTION
Soap notes:
She underwent dialysis on 13/06/22 ,10.pm
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