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65 YR OLD FEMALE WITH SOB

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. 


A 65 yr old female Home maker by occupation resident of Vangamarthi was presented to the OPD with chief complaints of :

Pedal oedema since 10 days 

decreased urine output since one week

On and off fever since one week

Shortness of breath since two days

HISTORY OF PRESENTING ILLNESS

the patient was apparently asymptomatic four years ago when she developed prolapsed uterus  for which she underwent hysterectomy And then she developed high grade fever. She was advised for some surgery? DJ stenting but patient denied it and is on conservative treatment.

 She has been taking NSA IDs for joint pain since four years

The patient complains of shortness of breath which is of grade 2

History of past illness:

 The patient was advised for some surgery? DJ stenting but patient denied it and is on conservative treatment.

No history of hypertension

No history of DM

No history of thyroid 

Personal history

Appetite normal

Diet mixed

Bowl and ladder moments regular

No known allergies

Consumes alcohol occasionally

No history of smoking


Family history

No significant family history


Examination

General examination

Patient is conscious coherent and cooperative

Patient moderately built and nourished

No pallor

No cyanosis

No lymphadenopathy

No icterus

No clubbing

Vitals

Temperature 98.6° F

PR 98bpm

RR 18 per minute

BP 110/80 mmHg

Systemic examination 

CVS

S1 S2 heard 

No murmurs

RESPIRATORY SYSTEM 

Position of trachea central

BAE +

No audible wheeze

Abdomen 

Soft, non-tender

Liver spleen not palpable

INVESTIGATIONS 















USG FINDINGS:
1.)E/O 6-7 mm calculus noted in contracted gall bladder

2.) E/O 24*21mm cystic leisons noted in lower pole of Rt kidney

3.) E/O multiple cysts noted in Lt kidney 

Impression:

1.) grade 1 in RT kidney and grade 2 in lt kidney changes with BL renal cortical cysts
2.) cholelithiasis

PROVISIONAL DIAGNOSIS:

Chronic renal failure

TREATMENT:

DATE: 7/6/2022

Tab Lasix 40mg /PO/BD

Tab nodosis 500mg /Po/BD

Inj epo 5000 IU/SC /once weekly

Inj iron sucrose 1 AMP in 100ml NS /OD

Tab shelcal 500mg /PO/OD

Tab orofer xt /PO / OD


DATE: 8/6/2022


Tab Lasix 40mg /PO/BD

Tab nodosis 500mg /Po/BD

Inj epo 5000 IU/SC /once weekly

Inj iron sucrose 1 AMP in 100ml NS /OD

Tab shelcal 500mg /PO/OD

Tab orofer xt /PO / OD

Tab pan 40mg/PO/BD






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