A 64 year old woman with SOB, decreased urine output since 3 days.

 

A 64 year old woman, who is a farmer by occupation, presented to the hospital with-


• 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) Ultrasound






Grade III Renal Parenchymal Disease


2) 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).


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.



DISCUSSION



1) Does overdosing OTC painkillers like common NSAIDS have an effect on Kidneys? If so, what effect can be seen? 


2) How do you diagnose Tuberculosis definitively?


3) What could be the reason for the failure of the patients' Kidneys?

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