case 35

60year old female
DOA -14/2024
DOD -29/4/2024
CKd DURATION -not known 


Diagnosis -
CHRONIC RENAL FAILURE

 Case History and Clinical Findings 
C/O FEVER AND SOB 2 MONTHS AGO C/O PEDAL EDEMA 2 MONTHS AGO

HOPI 
PATIENT WAS APPARENTLY ASYMPTOMATIC 2 MONTHS AGO, WHEN SHE DEVELOPED FEVER WHICH WAS SUDDEN IN ONSET ,RELIEVED ON MEDICATION .SHE ALSO HAD SHORTNESS OF BREATH WHICH WAS INSIDIOUS AND GRADUALLY PROGRESSED TO CURRENT STATE .SHE DEVELOPED PEDAL EDEMA WHICH IS INSIDIOUS ONSET ,GRADUALLY PROGESSIVE EXTENDING UPTO KNEE ,PITTING TYPE ,SLIGHTLY RELIEVED /DECRESED ON LYING DOWN .

PAST HISTORY 
K/C/O HTN SINCE 4 YRS ON CLONIDINE 0.1 MG PO/BD NO H/O DM ,TB, CAD
H/O CVA 1 MONTH AGO ( 1 TIA) 

PERSONAL HISTORY:
 MIXED DIET
DECRESED APPETITE
BOWEL AND BLADDER MOVEMENTS ARE REGULAR NO ALLERGIES
GENERAL EXAMINATION: 
VITALS:
TEMPERATURE- 97.8F
PR- 76BPM
RR- 19CPM
BP- 150/90MMHG
SP02- 90%
GRBS- 143 MG/DL
PEDAL EDEMA PRESENT
NO PALLOR , ICETRUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY
JVP NOT RAISED
SYSTEMIC EXAMINATION:
P/A- SOFT , NON TENDER
CNS:NO FOCAL NEUROLOGICAL DEFICITS PRESENT
CVS: S1, S2 HEARD, NO MURMURS.
RESPIRATORY SYSTEM:NORMAL VESICULAR BREATH SOUNDS HEARD.

Investigations


LFT 
TOTAL  Bilurubin0.73 mg/dl
Direct Bilurubin0.20 mg/dl
SGOT(AST)25 IU/L
SGPT(ALT)20 IU/L
ALKALINE PHOSPHATASE388 IU/L
TOTAL PROTEINS5.8 gm/dl
ALBUMIN3.0 gm/dl
A/G 

CUE -
ALBUMIN++++
SUGARNil

RFT
UREA125 mg/dl
CREATININE6.0 mg/dl
URIC ACID5.6mmol/L
CALCIUM8.3 mg/dl
PHOSPHOROUS4.2 mg/dl
SODIUM140 mmol/
POTASSIUM3.8mmol/L
CHLORIDE106 


HEMOGLOBIN 8.5 G/DL
MCV -77.7
MCH -28.1
MCHC-30.8
TOTAL COUNT 6100 CELLS/CUMM
PLATELET COUNT 1.53 LAKHS/ CUMM 

s.iron -76
S.ferritin -168.5


SMEAR NORMOCYTIC NORMOCHROMIC 

2D ECHO
RWMA PRESENT , ANTERIOR WALL AND LATERAL WALL HYPOKINETIC MODERATE TO SEVERE MR( MR JET AREA 11.32 CM2);ECCENTRIC MR MILD TO MODERATE AR (PHT 683 M/SEC) MODERATE TR WITH PAH;ECCENTRIC TR SCLEROTIC AV , NO AS/MS ; IAS - INTACT EF=44% RVSP= 50 MMhG
MODERATE LV SYSTOLIC DYSFUNCTION GRADE 1 DIASTOLIC DYSFUNCTION PRESENT MINIMAL PE PRESENT
IVC SIZE 2.16 CMS DILATED NON COLLAPSING DILATED RA/LA /IVC MILD DILATED LA/LV MAC INTACT.


USG
RT KIDNEY - 7X 3.1 CM LT KIDNEY- 7.1X 3 CM
BILATERAL SMALL KIDNEYS WITH GRADE 3 RPD CHANGES 
CHOLELITHIASIS

INTERVENTIONS
ORAL IRON THERAPY -DAILY TAB.OROFER XT
IV IRON THERAPY -TWICE /WEEK
EPO -YES
EPO DOSING -ONCE/2WEEKS
PRBC TRANSFUSED -0
ADMISSION IN ICU -0


Treatment Given(Enter only Generic Name) FLUID RESTRICTION <1.5 L/DAY
SALT RESTRICTION <2G /DAY
 INJ EPO 4000 IU ONCE WEEKLY
TAB. TELMA 40 MG PO OD
TAB. OROFOR XT OD
TAB. NODOSIS 500MG BD
TAB. DYTOR 40 MG PO BD
TAB. MET XL 12.5 MG PO OD
Inj.iron SUCROSE 1AMP IN 100ml ns IV OD ALTERNATE DAY 

 Advice at Discharge 
FLUID RESTRICTION <1.5 L/DAY
SALT RESTRICTION <2G /DAY
TAB. TELMA 40 MG PO OD
TAB. OROFOR XT OD
TAB. NODOSIS 500MG BD
TAB. DYTOR 40 MG PO BD
 TAB. MET XL 12.5 MG PO OD
Inj.iron SUCROSE 1AMP IN 100ml ns IV OD ALTERNATE DAY
INJ EPO 4000 IU ONCE WEEKLY

Follow up at 3months 
HB -10.2
MCV -80.3
MCH -28.5
MCHC -29.2
TLC -7600
PLT -3.12

Follow up at the end of thesis -patient has lost to follow-up.

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