57 yr old female case

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57 YEAR FEMALE WITH DECREASED URINE OUTPUT AND SHORTNESS OF BREATH

15/12/21 ,, 

8:28PM 

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

-micturition: Pt HAS DECREASED URINE OUTPUT.

GENERAL PHYSICAL EXAMINATION:

PALLOR - Present

Icterus - Absent

Cyanosis - Absent

Clubbing - Absent

Lymphadenopathy - Absent

Pedal oedema - PRESENT (NON 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

Ecg 

pedal edema

pallor

PLEURAL TAP was done 

PROVISIONAL DIAGNOSIS:

CKD with right sided pleural effusion

            TREATMENT:

1.Pleural tap

2. Head and elevation up to 30°

3. O2 supplementation if SpO2 is less than 90%.

4. Fluid restriction < 1 litre per day

5. Salt restriction < 2.4 G per day

6.Inj. Augmentin 500 mg/ IV/ OD

6. Tab. Azithromycin 500 mg/ OD

7. Inj. Lasix 40 mg IV/ BD

8. Tab

9. Tab shelcal 500 mg audi

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 /TD

14. Monitor vitals hourly

15. Strict I/O Charting, 

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

Pl ldh /sr ldh -1968/255 =7.7 

Pl protein /sr protein -3.6/5.4 =0.66

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 

Day 3

57yrs old female 

17/12/21 

Notes amc bed 3 

Yesterday in cubical no 2;

S

 pt feeling better 

 saturation without o2 92%

O: 

O/e pt c/c/c 

Temp 97.5 f

Bp 100/70 mmHg

 pr 115bpm 

RR 22cpm 

Grbbs 102 mg/dl 

I/O 500/1000ml 

Cvs s1s2heard no murmurs

Rs : 

BAE +

TRACHEA CENTRAL 

VESICULAR BREATH SOUNDS HEARD 

WHEEZE PRESENT 

P/A 

soft non tender 

Distended

Bowel sounds heard 

CNS :NAD 

PROVISIONAL DIAGNOSIS

CKD with rt sided pleural effusion 

Egfr 9ml/min( stage 5) 

EXUDATIVE >TRANSUDATIVE 

? INFECTION 

? MALIGNANCY 

1.Pleural tap

2. Head and elevation up to 30°

3. O2 supplementation if SpO2 is less than 90%.

4. Fluid restriction < 1 litre per day

5. Salt restriction < 2.4 G per day

6.Inj. Augmentin 500 mg/ IV/ OD( D3)

6. Tab. Azithromycin 500 mg/ OD (D3)

7. Inj. Lasix 40 mg IV/ BD

8. Tab

9. Tab shelcal 500 mg audi

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