A 55 year old female with complaints of shortness of breath
11/6/22
1701006103 General medicine long case
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:
Shortness of breath Since two days
Bilateral pedal edema since two days
Decreased urine output since two days
History of presenting illness:
No significant past surgical history.
No blood transfusions.
Personal history:
Diet mixed
Appetite normal
Sleep adequate
Bowel regular
Bladder decreased urinary output
No known drug or food allergies
No addictions
Family history:
No significant family history
General examination:
Patient is conscious, coherent and cooperative well oriented to time ,place and person
Well built and well nourished
Pallor present
Icterus absent
Clubbing absent
Cyanosis absent
Generalised lymphadenopathy absent
Edema present
Vitals
Pulse rate 106bpm
Blood pressure 160/80mmHg
Respiratory rate 34 cpm
SpO2 92 at room air
Temperature afebrile
Systemic examination:
Respiratory system:
Patient examined in sitting position
Inspection:
Examined in sitting position
Nose normal
Pharynx normal
Shape of the chest normal
Trachea central in position
Respiratory movements bilaterally symmetrical
Palpation:
No local raise of temperature
All inspectors findings are confirmed
Trachea central in position
Vocal fremitus normal
Percussion:
Resonant
Auscultation:
B/L air entry present
Normal vesicular breath sounds
Bilateral basal crepitations heard
Diffuse wheeze also present
Cardiovascular system:
INSPECTION:
No raised JVP
Chest wall bilaterally symmetrical
Apical impulse seen
Palpation:
Apical beat felt at 5th inter coastal space
No parasternal heave
Auscultation:
S1 S2 sounds heard
No murmurs
No thrills
Abdominal examination:
Shape of the abdomen scaphoid
Umbilicus normal
All quadrants of abdomen area moving normally
No scars sinuses engorged veins
Hernial orifices free
Palpation: soft non tender
https://youtube.com/shorts/NqMLPWBNQkw?feature=share
Liver not palpable
Spleen not palpable
Kidney not palpable
https://youtube.com/shorts/GxlPHCu_oB0?feature=share
Bowel sounds heard on auscultation
CNS examination intact
Investigations
Serum creatinine
HaemogramLFT
Blood urea
Chest X-ray
Provisional diagnosis : Chronic kidney disease with pulmonary edema and metabolic acidosis
denovo type 2 diabetes mellitus
Treatment
Dialysis was done after admission.
10/6/22
1)Inj.LASIX 40mg IV/BD
2)tab.NODOSIS 500mg PO/OD
3)tab.MET-XL 25 mg OD
4)tab.AMLONG 10mgOD
5)cap bio-D PO weekly once
6)tab. SHELCAL 500 mg PO OD
7)inj. Erythropoietin 5000 units weekly once
11/6/22
1)Inj.LASIX 40mg IV/BD
2)tab.NODOSIS 500mg PO/OD
3)tab.MET-XL 25 mg OD
4)tab.AMLONG 10mgOD
5)cap bio-D PO weekly once
6)tab. SHELCAL 500 mg PO OD
7)inj. Erythropoietin 5000 units weekly once
8)inj.INSULIN SC according to the GRBS
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