45 y/o F with reduced urine output, sob and facial puffiness
45 yrs old woman with reduced urine output, SOB, easy fatigability and facial puffiness
17 March 2022
Manvi Sharma
Roll no 88
2018
"THIS IS AN 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT."
A 45 year old female came to the OPD on 15th February 2022 with chief complaints of
-reduced urine output since 1 week
-easy fatigability from 1 week
-facial puffiness since 1 week and
SOB(grade 3) since 3 days
History of presenting illness-
The patient was absolutely alright 3 yrs back before she developed generalized weakness due to which she stopped doing her work of a daily wage labourer.
About 1 year back she developed severe right sided loin pain along with reduced urine output and generalized edema which was insidious in onset and gradually progressive. She went to the hospital and was diagnosed to have renal stones which were quite small in size for which she received medication and underwent DJ stenting. Hemodialysis was done twice. Her pain and urinary complaints reduced and she was fine for a year.
The subsequent year she could not recieve treatment due to prevalence of COVID load in the health facility.
She came to our hospital 1 month back with
-C/o reduced urine output since 1 week
Burning sensation during micturition +
Discontinuous stream of urine +
Incontinence +
No dribbling of urine
-C/o facial puffiness since 1 week
-C/o sob on walking for few steps itself(grade 3) from 3 days
No orthopnea, PND, chest pain, palitations, wheezing and cough
Vitals(on admission)
General physical examination - the patient is conscious, coherent and cooperative and well-oriented to time, place and person.
Pallor seen
No icterus, cyanosis, clubbing, lymphadenopathy, pedal edema
Systemic examination -
CVS- S1,S2 heard, no murmurs
Respiratory system- NVBS heard, BAE+
GIT- soft, non tender
CNS- NAD
On 15-2-22
Xray
ECG
Hemogram :
Hb-7.6
TLC - 27000
CUE :
ALB- +++
Pus cells- plenty
LFT :
TB- 1.6
DB- 0.33
Alkaline phosphatase - 222
ALB- 3
RFT:
Urea- 210
Creatinine- 11.4
Uric acid- 9.9
Phosphorous- 6.9
RBS: 75
Serology - negative
USG report revealed - b/l gross hydroureteronephrosis with paper thin cortex and echogenic debris in rt ureter(proximal & mid ureteric calculi)
2D ECHO -
NCCT KUB FINDINGS as on 17-2-22
On 23-2-22
ABG :
pH- 7.13
pCO2- 10.5
pO2- 115
HCO3- 3.4
stHCO3- 6.4
RFT:
Urea- 58
Creatinine- 3.6
Uric acid- 4.3
Phosphorous- 4.7
Provisional diagnosis -
B/l gross hydroureteronephrosis
B/l ureteric calculi
Post right sided DJ stenting
Plan of treatment :
1. INJ. LASIX 40 mg IV BD
2. INJ PAN 40 mg IV OD
3. INJ ZOFER 4 mg IV OD
4. INJ erythropoietin 4000 IU SC once weekly
5. Tab NODOSIS 500 mg PO BD
6. Tab OROFER XT PO OD
7. Tab SHELCAL PO OD
8. MONITOR VITALS
Post dialysis, she had episodes of vomitings, decreased intake of food and hypoglycemia. After 2-3 sessions , no episodes of vomiting occured.
Till date the patient has undergone 9 dialysis sessions over a stay of about 1 month in the hospital.
Plan of urology : Removal of the displaced DJ stent and renal stones and place another one after reducing creatinine levels.
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