62 year old with pedal edema and facial puffiness since 3 days

 Varsha Bandaru

Roll no 07

This is 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 patients 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 comment box is welcome.

I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan

CASE :

65 year old female farmer by occupation from sreerampelli came to hospital on 7/6/23 with chief complaints of fever 20 days back and pedal edema with facial puffiness since 20 days 


HISTORY Of PRESENT ILLENESS : 

Patient was apparently asymptomatic 30 years back then she developed fever and cough for which visited a local hospital where she was diagnosed with sputum positive TBand used ATT for 6 months and she recovered from then she was apparently asymptomatic 20 days back then she developed of fever for 2 days insidious onset , gradually progressive , low grade fever , intermittent in nature , relieved on medication , not associated with chills and rigors and weight loss.

2 days later H/0body pains  aggregavated while working in her farm  for which she used analgesics .
2 days later 
she developed pedal edema and facial puffiness 
Pedal edema - pitting type below the knees 
For which visited a local hospital in miryalaguda where she was told to have a kidney problem later she visited our hospital for the same problem where she was evaluated and was initiated on haemodialysis 
No history of decreased urine output, No history of haematuria 
No H/o burning , NO H/O shortness of breath , cough , palpations.
No H/O loss of consciousness , giddiness, involuntary passage of urine and stools . 

PAST HISTORY: 

K/C/O of TB 30 years back used ATT for 6 months 
Not a K/C/O HTN , ,Asthma , Epilepsy , CAD , CVD

PERSONAL HISTORY: 
 Appetite : lost 

Diet : mixed 

Sleep : Adequate 

Bowel and bladder movements: Regular 

Addictions : Toddy ( occasionally) 
 
Allergies : No allergies 

Family history: Not significant 

GENERAL EXAMINATION: 

Patient is conscious , cohorent , cooperative , moderately built and moderately nourished . 

Pallor : present 
Icterus : absent 
Cyanosis : absent 
Clubbing : absent 
Lymphadenopathy: absent 
Edema : present 








 






Vitals :

Temperature : afrebrile
Pulse rate : 102bpm
RR:
Blood pressure: 
Spo2:


Systemic examination :

Cardiovascular system:

Inspection 

Apperas normal in shape
Apex beat not visible 
No scars , sinuses , dilated veins 

Palpation: 
All inspectory findings are confirmed 
Trachea central in position 
Apex beat : 5 th intercostal space  .5cm from medial to midclavicular line

Auscultation:

S1 and S2 heard 


Respiratory system : 
Trachea centrally located 
Shape of chest : bilaterally symmetrical and elliptical

Auscultation: NVBS heard in infraaxillary, infrascapular and interscapular regions 

Central nervous system : 
No abnormal deficits 

Per abdomen : soft and non tender ; no organomegaly 
 Liver not palpable 
Spleen : not palpable

Bowel sounds heard
 
Provisional diagnosis ? Renal failure , AKI

Investigations : 

Hemogram




Ultrasound : Usg findings : 

E/ O Multiple cysts noted bilateral kidneys largest 
26*21mm in left side 
29*23 mm in right side 

Renal function tests and electrolytes:










Chest x ray






ECG : 



Final diagnosis : Polycystic kidney disease 
                           ? AKI on CKD
                           History of pulmonary TB 30 years back 


Treatment: 

Tab lasix 40 mg
Tab orofer 
Two session dialysis is done


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