38F with Pruritic rashes, pedal edema and sob with irregular menstruation.
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Patient was apparently normal 22 years back where she was married at her 11th standard with a guy who's family had a frequent disputes with her family... To calm down the disputes between the familes she was forced to marry him and got divorced with in a month by mutual understanding in the presence of their families and village heads. she described her childhood was joyful and attained menarche at 8th class(14yrs) since then her cycles was irregular at her 11th standard (18yrs) she got married with a guilt. She was been using medications to regularise her menses since 3 months before marraige and almost used for 20 years on and off..
2 years back as she didn't get her menses for 6 months she consulted her owner who is an Homeopathy doctor adviced her few homeopathic medications following which she got her regularised for next 6-8 months, after that even with homeo medication she had again irregular cycles.
Till date she was using medications to regularise her cycles on and off..
Since 1 month she had itchy lesions all over the body with few pus points on lower limbs visited local doctor used few topical medications but no relief in her symptoms.
15 days back one fine day she suddenly woke up from sleep with air hunger and felt breathless went nearest medical facility and took few medications and symptoms relived. Then she experienced that she had b/l pedal edema associated with decrease urine out put. Next day they went to gynecologist doubting that her irregular cycles may be reason for her breathlessness. On routine laboratory panel she was diagnosed with severe anemia. The she was prescribed with few medications and adviced for blood transfusion. For further evaluation and treatment patient came to our hospital.
Personal history :
Occupation - shop keeper
Diet - mixed stopped non veg 3 months back
Appetite - decreased since 5-6 days
Sleep - adequate
Bowel and bladder - decreased Urine output, passing stools.
Addictions : NO
Family history : no significant family history
General examination :
Pallor present
icterus absent
Edema of feet - present , hyperpigmented papules over body with pus points on lower limbs
No cyanosis , lymphadenopathy
Vitals :
Temp - afebrile (97.4 degree Fahrenheit)
PR - 90 bpm
RR - 16 cpm
BP - 120/70 mmHg
SPO2 - 99 % at RA
GRBS - 135 mg/dl
Systemic examination :
CVS :
S1 S2 +
JVP - elevated
No parasternal heave /thrills
RS :
BAE + , NVBS heard
P/A :
Abdomen -
Normal hernial orifices
No tenderness
No palpable mass
No organomegaly
No bruit heard
CNS - no focal neurological deficit present
Dermatology consultation was taken in view of Pruritic hyperpigmented papules
Investigations :
Hemogram :
HB - 4.2
TLC - 12,200
N/L/E/M - 78 /6/5/1
PCV - 12.8
PLt - 2.25
RBC - 1.48 millions
Peripheral smear :
Normocytic normochromic, with microcyes and tear drop cells,leucocytosis.
Serum LDH : #490.7
retic count : 0.7
Absolute retic count : 0.2
Reticulocyte index : 0.09
Indicates hypoproliferative marrow.
RFT :
Urea - 250
Creatinine - 14.3
Sodium - 141
Potassium - 4.2
Chloride - 98
LFT :
TB - 0.89
DB - 0.19
AST - 08
ALT - 04
ALP - 152
TP - 6.6
Albumin - 2.7
A/G ratio - 0.72
ABG
Ecg :
Ultrasound :
B/L kidney size deceased and echogenicity increased, CMD lost.
B/L grade 3 RPD changes,
B/L minimal pleural effusion
Diagnosis :
- heart'failure secondary to anemia/renal failure
ckd stage 5
Anemia secondary to crf
Disseminated eczema-? Uremic pruritis .
? AUB
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