A 41 YR FEMALE WITH CRF

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Hyndavi Konakanchi, Intern

23/12/22

A CASE DISCUSSION 41/F CASE WITH CRF

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 a diagnosis and treatment plan.

Following is the view of my case : 

A 41 year old female apparently asymptomatic   5 months back ; on one day when she is doing household work she developed giddiness, walking difficulty, sweating  --for which she went to some local hospital there she was diagnosed for the first time as hypertensive pt  with the blood pressure of around 210 

She was advised to get admitted in that hospital by the doctor but she denied it and went home –she used medications  for 2 days  but her symptoms didn’t resolve so she went to readmit in the same hospital again 

This time there is a hospital stay around 3 days : she had a new complaint of lower back ache – for which scanning was done –report showed 1 kidney size is swollen and other kidney is shrunken – there doctors also advised biopsy for which pt  got frightened and went home 

After going home she used medications for 4 days , she had a regular bp checkups ; bp used to be  normal ( acc .to pt & pt attenders)

At this time sister in law died ; because of which she had to travel  more and at this time her pain was increased . she continued regular medications for hypertension 

But from past 2 months  she developed b/l  pedal  edema  present weekly 3-4 times  which is on and off  it is aggravated on walking,standing,sitting for long hours and relieved on sleeping 

On 3/12/22, 5/12/22, 7/12/22, 9/12/22, 12/12/22 she took medications in outside hospital for which her pedal edema  got  relieved  and that doctor advised to take less spicy,salty,oily food & told to take decreased water intake 

On 12/12/22 ; she developed sob started while she is climbing upstairs ( sob grade 2 ) and doctors also advised to take dialysis for which she didn’t take in that hospital –came to our hospital to take dialysis here as it is free under arogyasree

Now on the presentation to our hospital she had complaints of sob on climbing stairs ( grade 2 SOB ),low back ache

ALCOHOL CONSUMPTION HISTORY :

She started alcohol consumption 2 yrs back : first she started with her sister in law in a function and then she started to like the feeling after consuming alcohol so she started drinking alcohol 3-4 times a week .

She used to drink quarter , with her cousins or even alone 

Around 4 ½ months back ; After she had scanning ( USG) done and diagnosed to have 1 kidney swollen and other shrunken – doctor advised to stop drinking after which she had drunk 2-3 times  and stopped for some days  & again when her sister in law died she drank 2-3 times  in that period of time with their relatives  

From that time she stopped drinking totally

DAILY ROUTINE :

She is a farmer by occupation 

She wakes up at 4 am in the morning  ; freshens up and does household activities 

She goes to farm by around 8 am in the morning along with her lunch box

She returns home by 6/7 pm in the evening and does household activities ; freshens ;

Drinks sometimes 3-4 times mostly alone , sometimes with their relatives and and sleeps by 8/9 pm

She eats rice and curry morning, afternoon, night 

After her scanning was done approximately 4 ½ months back doctor advised to take less spicy ,salty,oily food and from 6 stopped going to farm work due to some personal family reason ; which is not related to her health 

And from 4 1/2 - 5 months she is not doing any household activities because of health condition , she is unable to do

MEDICAL HISTORY:

* She is a known case of HTN since 5 months and on regular medication

Not a K/C/O DM/ asthma / Ischemic heart disease / epilepsy / TB

FAMILY HISTORY

No significant family history 

PERSONAL HISTORY 

OCCUPATION : Farmer

DIET : Mixed 

APPETITE : Normal 

SLEEP : Normal

BOWEL AND BLADDER HABITS : Normal

ADDICTIONS: No

GENERAL EXAMINATION 

* Patient is concious coherent and coperative, well oriented to time palce and person

* Built - moderately built , moderately nourished 

VITALS 

Blood pressure : 140/80 mm hg

Pulse Rate : 98 bpm

Temperature  : 98.6 degrees  F

SPO2 : 98 @ RA

GRBS : 102

PALLOR : PRESENT 

* NO ICTERUS , CYANOSIS, CLUBBING , LYMPHADENOPATHY 

                        

SYSTEMIC EXAMINATION

CVS EXAMINATION

Inspection- 

* The chest wall is bilaterally symmetrical

* No raised JVP.

Palpation-

* Apical impulse is felt in the left 5th intercostal space,  medial to the midclavicular line

* No parasternal heave felt.

Percussion-*resonant note heard-  no pericardial effusion

Auscultation-

## Mitral area , aortic area , pulmonary area 

* S1 and S2 heard, no added thrills and murmurs are heard

PER ABDOMINAL EXAMINATION :- 

Inspection:

* Abdomen is distended

* Umbilicus is inverted

Movements :

 * Gentle rise in abdominal wall in inspiration and fall during expiration. 

* No visible gastric peristalsis 

palpation : 

* SOFT, NON TENDER, NO ORGANOMEGALY

Percussion: 

Resonant note heard

No fluid (ascitis) 

Auscultation:

* Normal bowel sounds.

RESPIRATORY SYSTEM EXAMINATION :-

Inspection-

* Upper respiratory tract - Normal

* Shape of chest - elliptical & Bilaterally symmetrical 

* Trachea- in midline

* no scars and sinuses

* no visible pulsations

* no engorged veins

* no usage of accessory respiratory muscles

Palpation-

* No local rise of temperature

* No tenderness

* All the inspectory findings are confirmed 

* Apical Impulse :- 5th intercostal space 1 cm medial to mid clavicular line

* Trachea is in normal position. 

* chest expansion - normal.

* Movements of chest with respiration are normal.

 vocal fremitus - normal.

                     

Ausclutation-

* Bilateral air entry - present.

* Normal vesicular breathsounds are heard.

* No advantitious sounds heard.

CNS EXAMINATION :- 

* No focal neurological deficits 

* Higher motor functions are normal 

DIAGNOSIS : 

CRF WITN HTN 

TREATMENT: 

1) TAB. LASIX 40 MG PO /BD

2) TAB.NICARDIA 10 MG PO/TID

3) TAB.NODOSIS 500 MG PO/BD 

4) TAB.SHELCAL 100 MG PO/OD

5) CAP BIO D 3 PO/OD 

6) INJ.ERYTHROPOIETIN 4000IU S/C WEEKLY ONCE AFTER HD

7) INJ.OROFER XT PO/OD 

8) SALT RESTRICTION <1.5 gm / DAY & WATER RESTRICTION < 1.5 lts / DAY 

9) INJ.IRON SUCROSE 100 MG + 100 ML NS   IV WEEKLY ONCE