Chronic kidney Disease with left side pleural effusion .
5 7 year old female with chronic kidney disease
With left side pleural effusion .
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Date of admission 15/12/21.
A 57 years old female patient who is homemaker came to casuality with cheif complaint of decreased urine output since 3 days
C/o shortness of breath since 1 day
C/o cough intermittent type with yellowish sputum
C/o fever not associated with chills.
Daily routine : patient daily get up at 6 0 clock have breakfast at 9 o clock . Then she goes to daily wage work .she return home by 5 pm in evening then she have dinner at 8 o clock . Sleeps at 10 pm .routine after development of generalized weakness since 5 years she stop going to work.
History of present illness :
Patient was apparently asymptomatic 5 years back.Then patient developed pain in lower back region which is radiating to groin for this she visited a hospital there she diagnosed with renal caliculi managed conservatively by taking medicine. In Follow back she diagnosed with acute kidney injury for this she is taking treatment conservatively from past 5 years.
Now she developed shortness of breath grade 2
, fever , decreased urinary output and cough yellowishwhite sputum tinged with blood
Patient have pain in left hypochondrium region..
Patient has undergone 3 sessions of hemodialysis .
Past history :
Patient is not a known case of Diabetesmellitus , hypertension , asthma , tuberculosis, epilepsy
.patient has undergone hysterectomy 10 years back.
Menstrual history : menarche.
Family history :
No similar complications are seen in family members.
Drug History :
Patient is not allergic to any known drug.
Personal history :
Diet : mixed
Appetite : normal
Sleep : adequate
Bowel movement normal
Micturation : decreased
Allergies : no known allergies
Addictions : not addicted to alcohol and smoking.
General physical examination :
Patient is pallor
Bilateral pedal edema - nonpitting type is seen.
No cyanosis
No clubbing
No icterus
Well built moderately nourished
No cerviacal lymphadenopathy
Vitals :
Temperature : 98.8°f febrile .
Blood pressure: 100/80 mm of hg
Respiratory rate : 18 cycles per minute
Pulse rate : 75 beats per minute .
Spo2 : 84%
GRBS : 154 mg
. systemic examination :
Cardiovascular system :
S1 and S2 heard
No murmurs heard
No thrill is felt
No precordial bulging in seen .
Respiratory system :
Position of trachea is central
Patient experiencing dysopnea .
Wheezing sounds heard
Breathing sounds are vesicular .
Per abdomen :
Inspection :
Shape of abdomen : schaphoid
Palpation
No tenderness in abdomen
No palpable masses are seen.
Hernial orifice normal.
Free fluid no
Auscultation :
Bowel sounds are heard.
Central nervous system :
Patient is conscious coherent and cooperative with time place and person.
Speech is normal
Cranial nerve , motor system and sensory system are functioning normal .
Provisional Diagnosis :
Patient is diagnosed with CKD along with right sided pleural effusion associated with fever .
Investigations:
LFT :
ALT 61
ALP 163
ALB 2.1
TP 5.8
ABT 48
ALG 0.57
ABG : ph 7.25
Pco2 34%
Pco2 51 %
Pleural fluid :
LDH : 1968
Pleural sugar ; 71
Protein : 3.6
Serum LDH 255
Serum protein 5.4g /dl
Hemogram:
Cell count pleural fluid :
Serum albumin level :
Serum iron :
Ultrasound report form :
Cytology report :
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