Case ( 2) 64 yr old woman with dry cough(6yrs), SOB (3days),decreaed urine output(3days)
• dry cough since 6 years
• SOB since 3 days
• decreased urinary output since 3 days.
Date of admission - 2pm, 16/08/21.
HISTORY OF PRESENT ILLNESS
• PT was apparently a symptomatic 6 years back.
• PT started getting intermittent cough since then.
• She wrongly self-diagnosed herself with Tuberculosis and started using her husband's TB medication on SOS basis.
• The patient also took medication to manage pain on SOS basis.
• Her intermittent cough turned persistent over the last 3 months and got admitted to a hospital ( in their mandal) suspecting it was Covid19.
• The hospital later diagnosed her with kidney failure and DM.
• The doctor who prescribed the medications for her kidney failure 3 months back, was not aware of the other medications she was taking (TB medications).
• The patient joined the current hospital on the basis of referral.
• 3 days back, the patient starting losing her consciousness, she wasn't talking much. There was no urination on that day.
• 2 days back, she presented with body pain, skin itching, and bloating of stomach.
• Approximately 12 hours after admission, the patient underwent a 2 hour dialysis.
PAST HISTORY
• The patient suffers from Diabetes Mellitus.
• The patient doesn't suffer from Tuberculosis.
• The patient also doesn't suffer from asthma, epilepsy, and hypertension.
• The patient has undergone 3 deliveries, all vaginally.
• She underwent a hysterectomy after her 3rd child was born.
• She was never involved in any kinds of accidents.
PERSONAL HISTORY
• The patient consumes a mixed diet of vegetarian and non vegetarian food.
• She is of ectomorphic built.
• She appears to be malnourished.
• Before 3 months, she had no complaints of constipation or urination problems.
• There was a gradual onset of constipation, and burning upon micturition.
• She started smoking since she was 10 years of age.
• On an average she consumed 10 cigars (chutta) per day.
• As her age progressed, she apparently reduced smoking drastically.
• She had completely cessated smoking cigars from the past 2 to 3 years.
• She is an alcoholic.
• Apparently, the patient consumed alcohol liberally during family gatherings and festivals.
• The patient was hesitant to disclose how much was consumed by her per day.
• Apparently, sometime around 40 years of age, patient had menopause.
FAMILY HISTORY
• No one in her family complains of a similar problem with similar presentation.
• No one in their family suffers from any genetic conditions or deformities.
• As far as the patient knows, all the deaths in her family were by natural causes.
• The patient's husband is a known case of Tuberculosis.
• The patient's husband also had episodes of epilepsy.
ALLERGY HISTORY
• Patient is not allergic to any known drug or food.
• There is no known allergy to dust or pollen in the patient.
DRUG HISTORY
• Patient was liberally taking Tuberculosis medication whenever she was presented with a cough without consulting a physician.
• She has also taken pain killers on presentation of pain without consulting a physician.
• The doctor prescribing medication for her renal disease was not aware of the other medications she was taking without doctor consultation.
• Patient also takes Metformin to maintain her glucose levels in blood.
• On enquiry, the patient refused to have taken any sorts of steroids, insulin, antihypertensives, diuretics, ergot derivatives, monoamine oxidase inhibitors, hormone replacement therapy or contraceptive pills — prior to coming to the hospital.
GENERAL EXAMINATION
• The patient is conscious, coherent but not cooperative.
• Her attitude seemed dismissive.
• On examination, patient appears to be a little fatigued.
• Her build is ectomorphic.
• The patient has oedematous face.
• No decubitus is present.
• Patient has substantial pallor and pale tongue; appears to be anemic.
• Patient appears to be mildly dehydrated.
• Vitals (on examining)
Temperature- 99.3°F
Pulse Rate- 88bpm.
S1 and S2 are heard.
spO2- 97.
Blood Pressure is 120/70.
PROVISIONAL DIAGNOSIS
Chronic Renal Failure.
INVESTIGATIONS
1) Hemogram
Haemoglobin levels are 6.8% (reduced).
Random Blood Glucose is 233mg/dl (elevated).
Blood Urea is 139 mg/dl (elevated).
Serum Creatinine is 7.1 mg/dl (elevated).
Serum Uric acid is 11.7mg/dl (elevated).
Serum Amylase is 533 IU/L (elevated).
Serum Lipase is 180 IU/L (elevated).
Albumin is 3.2 g/dl (reduced).
CRP is 26.3 IU/L (elevated)
.2) ultrasound
Grade III Renal Parenchymal Disease
CLINICAL DIAGNOSIS
Chronic Renal Failure with Uraemic Encephalopathy.
TREATMENT
INJ NaHCO3 100meq IV stat
INJ Piptaz 4.5g IV stat --Hb-->
INJ Piptaz 2.25g IV/TID
INJ PAN 40mg IV/OD
INJ Zofer 4mg/IV/SOS
TAB Nodosis 500mg PO/TID
TAB Shelcal PO/OD
TAB Orofer XT PO/BD
INJ Erythropoietin 4000IU/SK
Weekly twice
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