30 year old female with pedal edema and shortness of breath

6-6-2022

Medicine final exam long case

M.Srilekha

 I have 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 diagnosis and treatment plan.

Chief complaints:

Abdominal pain since 5 days 

Facial puffiness and pedal edema since 2 days

Shortness of breath since two days


History of presenting illness:

The patient was apparently asymptomatic 3 months back then she developed facial puffiness and bilateral pedal edema which was pitting type.

Abdominal pain since 5 days which was sudden in onset and of burning type and there are no aggravating and relieving factors.

Later she developed shortness of breath Which was insidious in onset and gradually progressed to grade 4(shortness of breath at rest ) no change on position change and no aggravating and relieving factors.

No history of fever, sore throat ,joint pains.

Past history:

Known case of hypertension since 12 years and on medication.

Known case of chronic renal failure and maintained on dialysis

Total 5 dialysis done in month of may and 4 in June 

Not a known case of Asthama, TB, epilepsy, diabetes mellitus, thyroid disorders

No significant past surgical history.

Personal history:

Diet vegetarian 

Appetite decreased 

Sleep Inadequate 

Bowel and bladder regular

No known drug or food allergies 

No addictions

Family history:

Mother known case of hypertension.

General examination: 

Patient is conscious, coherent and cooperative well oriented to time ,place and person

Pallor present

Icterus absent 

Clubbing absent

Cyanosis absent 

Generalised lymphadenopathy absent 

Edema pitting edema 

Vitals

Pulse rate 120bpm

Blood pressure 150/90 mmhg

Respiratory rate 34 cpm 

Temperature afebrile 

Systemic examination:

Respiratory system:

Patient examined in sitting position 

Inspection:

Nose normal

Pharynx normal

Shape of the chest normal

Respiratory movements bilaterally symmetrical reduced

Trachea central in position 

Nipples at 4th intercostal 

Apex impulse seen at 6th inter coastal space

Palpation:

Trachea central in position

Apical impulse felt ay 6th ics 

vocal Fremitus reduced on both sides In infra axillary  and infra scapular.

Percussion:

Dull note

Auscultation: 

diminished breath sounds on both sides 

Cardiovascular system:

JVP not raised 

Visible pulsations

Apical pulses shifted downward and laterally to 6th inter coastal space.

Thrills absent 

S1 S2 muffled sounds heard

Pericardial rub present

No murmurs

Abdomen examination:

Inspection:

Distended

Umbilicus: normal in position inverted 

Movements all quadrants moving normally 

Visible pulsations absent 

surface of abdomen normal

Palpation: 

Liver not palpable

Percussion dull

Auscultation:bowel sounds heard

Investigations:








USG:
2D echo
Chest X-ray :
Pleural tap done:

Provisional diagnosis: CKD secondary to hypertension with heart failure ,
pleural effusion and pericarditis.


Treatment:
Inj.MONOCEF 1gm/IV/BD
Inj.PAN 40mg/IV/OD
Tab.LASIX 40mg BD
Inj.METROGYL 400mg/IV/tid
Inj.BUSCOPAN/iv/stat
On haemodialysis 
Inj.KCL 2 amp in 500ml NS









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