65 F with B/L pedal edema, facial puffiness and decreased urine output

  This case has been given to solve in an attempt to understand and analyse the patient's clinical data, and develop my competency in reading and comprehensive study on the clinical data including history, clinical findings, investigations, and coming up with diagnosis and treatment plans. This is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.




MED CASE :

65 F with B/L pedal edema, facial puffiness and decreased urine output. 


CHIEF COMPLAINTS: 


Patient came With complaints of B/L pedal edema, facial puffiness and decreased urine output. 


HISTORY OF PRESENTING ILLNESS: 


Pt was apparently asymptomatic until 4 days back, then she developed blisters of toes of both legs, after which she developed bilateral pedal edema and facial puffiness, associated with decreased urine output.

H/o fever, burning micturition, associated with itching are present. 

H/O pain in the right flank region since 5 days. 

No H/O cough, orthopnea, SOB, PND.

No H/O Similar complaints in the past.



PAST HISTORY: 


H/O DM since 2 years , on OHAs.

K/C/O CKD since 6 months, not on conservative management.

Not a K/C/O HTN, CVA, CAD, Thyroid disorders, epilepsy, asthma, TB. 

No history of previous surgeries in the past.


PERSONAL HISTORY:

Diet- mixed. She is on a soft diet.

Appetite- normal

Sleep- adequate

Bowel- normal. 

Bladder- burning micturition present. 


ALLERGIC HISTORY:


No allergic history to any kind of food or drugs.


GENERAL EXAMINATION:


THE PATIENT IS CONSCIOUS, COHERENT AND CO COOPERATIVE 


PALLOR is present

No ICTERUS 

No CLUBBING

No CYANOSIS

No LYMPHADENOPATHY

EDEMA subsided. 



TEMPERATURE: Afebrile 


PR:104bpm


BP:140/80mmhg


RR:16cpm


GRBS: 130 mg/dl



SYSTEMIC EXAMINATION:


CVS: S1 S2 Heard. No murmurs heard.


RS: BAE +. Normal vesicular breath sounds heard. No added sounds.


ABDOMEN EXAMINATION:


Inspection: 

Abdomen is distended. 

No sinuses,scars, pulsations, peristalsis.

Umbilicus is central and inverted. 

All quadrants of Abdomen move equally with respiration.


Palpation: 

Abdomen is soft on palpation and no tenderness noted in any quadrants. 


Percussion:

Resonant note is heard on percussion

shifting dullness negative


Auscultation:

Bowel sounds are heard.



CNS: No Focal Neurological Defects. 







INVESTIGATIONS:


28/8/23 :


Hemogram: 

Hb: 8.7

TLC : 9700

PCV: 27

MCV: 85.7

MCH: 27.6

PLT COUNT: 2.83 Lakhs


RFT: 

Urea: 132

Creat: 5.9

Uric acid: 8

Na: 140

K: 4.8

Cl: 104


FBS: 60 mg/dl


RBS: 82 mg/dl


LFT: 

TB: 0.6

DB: 0.2

AST: 9

ALT: 7 

ALP: 181

TP: 7.2

ALB: 3.58

A/G Ratio: 0.99


Serum iron: 74 ug/dl


CUE: 

ALB: ++

Sugar: nil

Pus cells: 3-6

RBC: 2-3

Crystals: Nil

Casts: Nil


Anti HCV: non reactive 


HIV: non reactive 


HbsAg: non reactive 



2D ECHO on 29/8: 

Impression: 

- Moderate TR + with PAH 

- Mild to moderate AR +, Mild MR +

- Sclerotic AV. No AS/MS.

- EF = 60. 

- Good LV systolic function.

- Diastolic dysfunction

- No PE

- IVC size (1.32 cms) 

- Mild diluted RA/ LA. 


29/8/23 :

ABG: 

pH: 7.24

PCO2: 27

PO2: 51.8

HCO3: 11.2

O2 SAT: 86


31/8:

Hemogram: 

Hb- 7.4

TLC- 6000

PCV- 24

MCV- 87.8

MCH- 28

PLT COUNT: 1.62 lakhs


RFT:

Urea: 62

Creat: 3.5

Na: 136

K: 4.8

Cl: 99


2/9/23:

Hemogram: 

Hb- 7.4

TLC- 8600

PCV- 23

MCV- 86.8

MCH- 28

PLT COUNT: 1.72 lakhs


RFT:

Urea: 52

Creat: 3.5

Na: 137

K: 4.7

Cl: 104


3/9/23:

Hemogram: 

Hb- 7.8

TLC- 12000

PCV- 23

MCV- 86.8

MCH- 28

PLT COUNT: 2.12 lakhs


RFT:

Urea: 75

Creat: 4.5

Na: 133

K: 4.4

Cl: 95


4/9/23 :

Hemogram: 

Hb- 7.8

TLC- 11200

PCV- 24

MCV- 87.8

MCH- 28

PLT COUNT: 2.2 lakhs


RFT:

Urea: 94

Creat: 5.6

Na: 140

K: 4.3

Cl: 101



DIAGNOSIS:


CHRONIC KIDNEY DISEASE - STAGE 5.

WITH TYPE 2 DM 



COURSE IN THE HOSPITAL:


The patient was brought to casualty with complaint of B/L swelling of both limbs, SOB and facial puffiness. She also had decreased urine output as well. 


The laboratory tests were done and the Hemogram report has shown that she had severe Anemia and RFT has shown Deranged urea and creatinine levels for which the treatment was initiated. The patient was suspected to have Acute kidney injury and possible Chronic Kidney disease (CKD) and therefore its necessary treatment was initiated immediately. 


The patient was admitted in nephrology department and all the necessary investigations were done. Her Blood pressure was normal but GRBS was low (50mg/dl) at the time of admission which was treated immediately. 


Patient was asked for consent for central line and hemodialysis on 29/8 to treat the condition that is, Chronic kidney disease. The patient and the attenders were informed about the risks of the procedure as well. 


The patient underwent dialysis 4 times since the time of admission. Patient had SOB, shivering and fluctuations in blood pressure during the 1st and 4th dialysis sessions. 


The bilateral pedal edema and facial puffiness has slowly reduced. Her urine output has slowly improved as well. 


Her bowel activity is normal. However, the patient has burning micturition and itching. 


Her appetite is adequate and no disturbance in sleep during the course of hospital admission. 










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