A 65 year old female with fever, pedal odema and facial puffiness

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


65 year old female farmer by occupation 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 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 



Poor oral hygiene and tobacco staining 






Vitals :


Temperature : afrebrile

Pulse rate : 102bpm

RR:18/cpm

Blood pressure: 130/80



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 : 











Ultrasound : Usg findings : 


E/ O Multiple cysts noted bilateral kidneys largest 

26*21mm in left side 

29*23 mm in right side 


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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