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: 
Patient was apparently asymptotic six years back and then developed bilateral pedal edema for which she visited hospital and diagnosed with hypertension and renal failure
And was on conservative management 
Since two days patient is having shortness of breath grade 4 (MMRC grading) not associated with chest pain sweating
Bilateral pedal edema since two days pitting type and 
Decreased urinary output since two days no burning micturition ,there is increased hesitancy and frequency .
Past history: 

Known case of hypertension and ckd since 6 years 
Denovo type 2 diabetes mellitus ( diagnosed after coming to our hospital- GRBS 418mg%)
Not a known case of Asthama 
                                  CAD 
                                  TB

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

Haemogram
LFT
Blood urea 

Chest X-ray 
2D echo 
https://youtube.com/shorts/xW9KV3WopBE?feature=share


 Left Ventricular hypertrophy



Urine for ketone bodies
Complete urine examination
ECG





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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