2. Personal History
• Female patient named Fahima Hussein El-
Gabassy aged 67 years old, from El Manzalah,
house wife.
• Married has 3 offspring youngest of them is
33 years old.
• No special habits.
3. Complaint
• Swelling of both lower limbs.
• Difficulty of breathing.
• Decrease urine output.
4. Present history
• The condition started about 2 weeks ago with
gradual onset and progressive course of swelling
of her lower limbs associated with difficulty of
breathing and easy fatigability.
• Dyspnea was grade IV (at rest), which increase
by lying flat, aggravated by effort and relived by
setting. Associated with non-productive cough.
5. Present history
• The patient was diagnosed as CKD 3 years ago,
with basal creatinine 3.8 mg/dl.
• eGFR = 16.8 ml/min/1.73 m2
• Oliguria 1 week ago.
• Bi-lateral, pitting oedema of both lower limbs
below knee.
• History of DM 30 years ago on insulin and HTN
20 years ago on amlodipine.
6. Menstrual and obstetric history
• Menopause at age of 46 years.
• Gravida III, para III.
• Last delivery 33 years ago.
7. Past history
• A similar attack 1 y ago, with
dyspnea and over-loaded and relived
by 6 HD sessions in our hospital.
• History of right radio-cephalic AV
fistula 11 months ago.
11. General ex
• Patient was fully conscious, alert and
oriented to time, person and place.
• Appearing very ill, obese, orthopnic and
pale.
• BMI 33.
• Neck examination non- congested neck
vein and no palpable mass.
13. Local ex
• Chest: vesicular breathing with prolonged
expiration and bilateral basal crepitation.
• Heart: normal S1 and S2 no murmur or added
sound.
• Abdomen: normal contour of the abdomen, no
scars, no pigmentation. The abdomen is lax and
soft.
• LL: bilateral pitting oedema of both lower limbs
below knee and intact peripheral pulsation.
15. I. U/S
• liver average size, bright echo-pattern, no focal
lesion.
• Gall bladder distended, no stones
• Spleen normal size, site, shape with no focal
lesion
• Kidney
Right: size (7 X 4.5 cm), increase echogenicity
Grade II, poor CMD. No back pressure or cyst.
Left: size (8 X 4 cm) normal echogenicity poor CMD,
mild back pressure with lower polar cyst measures (
1.5 X 1.5 cm).
23. Day 23rd of December
• Lasix 40 mg ampule /6 hs
• Patient was seen by cardiologist and
adviced:-
Nitroderm patch 10 mg.
Amlodipine 10 mg tabs / day.
24. Day 26th of December
• Patient received HD session via
right radio-cephalic AV fistula.
• Increase dose of Lasix up to 80
mg / 8 hs.
25. Day 27th of December
• Patient was seen by the cardiologist
and advised:-
• Lasix 80 mg / 8 hs
• Amlodipine 10 mg tabs / day.
26. Day 28th of December
Patient received the second HD
session.
30. Conclusion
• Chronic kidney disease, fluid over-load and
diuretics is a complicated triangle.
• Despite of diuretic benefits in management of
fluid over load in chronic kidney disease
patient, their use is associated with adverse
renal outcomes.
