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

 Varsha Bandaru

Roll no 07

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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