Long case for final examination - 22 year old female with edema and decreased urine output

 9th semester

Roll no. 1701006121

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 a diagnosis and treatment plan. 

CASE : 

22 years old female , daily wage labourer by occupation ,resident of miryalguda was bought to the opd with chief  complaints of

 • no urine output since 5 days

 • generalized edema since 5 days

HISTORY OF PRESENTING ILLNESS : 

• Patient is a known case of diabetes mellitus and hypertension. At the age of 10 years, she had fever, increased appetite and increased frequency of micturition for which she was taken to a hospital where she was diagnosed with diabetes. 

•She was on oral hypoglycemic agents for 1 year and later she was kept on insulin 2 times a day. 

•Later, 2-3 years back she was in altered sensorium for which she was bought to the hospital. She had hyperglycemia and the dose of insulin was increased. 

• 20 days back she was bought to the opd with generalized edema , decreased urine output and diagnosed with renal failure and nephrotic syndrome. She was dialysed 5 times and 1 unit of blood transfusion was done. She got discharged. 

• She got admitted again for the same 

complaints. 

• The edema first started around the eyes which was more in the morning and decreased towards the end of the day. Later it progressed to involve the entire body.Decreased urine output since 15 days. Later since 5 days there is no urine output.No hematuria, No loin pain, No history fever or sore throat recently. 

PAST HISTORY :

Patient is a known case of diabetes since 12 years and hypertension since 1 year. 

No h/o Tb, epilepsy, asthma

No previous surgical history

FAMILY HISTORY :

No history of diabetes or hypertension in the family

PERSONAL HISTORY :

Diet - mixed diet

Appetite - decreased appetite since 6 months

Sleep - adequate

Bowel movements - regular

Bladder movements - normal before 20 days

No addictions 

No food or drug allergies

MENSTRUAL AND OBSTETRIC HISTORY :

Attained menarche at the age of 11  years

Regular cycles - 5/30

No pains, No clots

Married 1 year back

2 months of Amenorrhoea 3 months back. 

She was pregnant diagnosed based on ultrasound. 

On ultrasound , it was found out that there was no cardiac activity of the fetus and she got aborted. 

Since then she have no menstrual cycles. 

GENERAL EXAMINATION :

Patient is examined in a well lit room after taking the consent. 

She is conscious, coherent and cooperative. 

Well oriented to time, place and person. 

Pallor - present                    

Icterus - absent

Cyanosis - absent

Clubbing - absent

Generalized Lymphadenopathy - absent

Bilateral pedal edema - present

She has generalized edema ( anasarca) 

VITALS :

Pulse - 88 beats per minute, regular in rhythm, normal in volume and character of vessel, no radio- radial delay, no radio - femoral delay. 

Respiratory rate - 20 cycles per minute

Blood pressure - 140/80 mm of hg, measured in the left arm in supine position

Temperature - afebrile 

Spo2 - 96% at room air

GRBS - 203 mg/dL 

SYSTEMIC EXAMINATION : 

CVS : 

    

S1 S2 heard, no murmurs

CNS : 

No neurological deficit

ABDOMINAL EXAMINATION : 

Inspection - abdomen distended 

                      Umbilicus is normal in shape and                              position

                      No visible scars or sinuses

                      No visible gastric peristalsis

                      No distended veins

Palpation - No local rise of temperature

                     No tenderness

                     Organs couldn't be palpated

Percussion - fluid thrill present

Auscultation - bowel sounds normal

RESPIRATORY EXAMINATION :

Examination done in sitting position. 

Inspection of URT - normal

Inspection of LRT - Trachea is central in position. 

                                    Chest is symmetrical. 

                                    Movement of the chest is                                              equal and thoraco-                                                       abdominal type of breathing. 

Palpation - Trachea is central in position. 

                     Chest is expanding symmetrically. 

                     Vocal fremitus decreased in                                        inframammary, infraaxillary and                              infrascapular area on both sides. 

Percussion - Stony dull note in inframammary,                              infraaxillary, infrascapular area on                          both sides. 

                        On tidal percussion, dullness                                       persisted on right side. 

Auscultation - Bilateral air entry present. 

                          Normal vesicular breath sounds. 

                          Decreased breath sounds in                                        inframammary, infraaxillary,                                      infrascapular area on both sides. 

INVESTIGATIONS : 

Hemogram:

Blood urea - 127mg/dL

Serum creatinine - 6.7mg/dL

Ultrasound :

Chest Radiograph :

Serum electrolytes : 

Sodium - 136 mEq/L

                           Potassium - 3.5 mEq/L

                            Chloride - 97 mEq/L

DIAGNOSIS : 

Chronic kidney disease on maintenance hemodialysis  with bilateral pleural effusion. 

TREATMENT : 

• Inj. LASIX 60mg/ IV/ BD

• INSULIN INFUSION  6ml / hr

   1ml of insulin in 39ml of normal saline

• Tab. NICARDIA 20mg/ PO / BD

• Tab. TELMA  40mg/ PO / BD 

• Nil by mouth

• Fluid and salt restriction

• Hourly monitoring of GRBS