1601006166 LONG CASE

 

1601006166 LONG CASE - GENERAL MEDICINE

This  is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 


LONG CASE :

A 56 year old female, resident of Raselpuram who is farmer by occupation went to a hospital in Nalgonda 5 yrs back with complaints of severe back pain radiating to lower abdomen and groin,fever and burning micturation and was diagnosed as Renal stones. 
After 1 yr she again visited the hospital for followup checkup then was diagnosed as Chronic Kidney disease for which she was on medical treatment for 4 yrs and now on MHD since 3 months.
Now she presented with complaints of :

Shortness of breath since 2 months
Swelling of legs  since 2 months

shortness of breath was insidious in onset, gradually progressive from grade 2 to grade 3(NYHA grading). Aggrevated on walking and while performing daily activities. Worsens at night and on lying down, releived on medications initially (Lasix) but later on it is not releived by medications also.
H/o reduced urine output.

No h/o fever, chills, cough, hemoptysis, sputum production,
No h/o chest pain, palpitations,  syncope
No h/o abdominal pain, abdominal distension , nausea, vomiting, and diarrhea. 

Past history :

K/c/o  HTN since 7 yrs ( visited to the hospital with complaints of headache and neck pain) - on medication (Telmisartan) (used medication irregularly)

No h/o DM ,Thyroid disorders, Asthma, Epilepsy,TB, coronary artery disorders

Menstrual history:

Age of menarche :13 years, 
Regular cycles : 5/30 days
Menopause attained at 50 years

Family history: 
    Not relevant 

Personal history: 
Diet:Mixed
Appetite: Decreased
Sleep: Decreased
Bowel: Regular
Bladder: Decrease urine output
No addictions

Drug history: 

NSAIDS (diclofenac) for renal pain 
Telmisartan for HTN
No known drug allergies

General examination:-  (consent obtained)

The patient is conscious, coherent, cooperative , well built and well nourished. Well oriented to time,place and person.

Pallor-present
Clubbing- absent
Cyanosis- absent
Koilonykia- absent
Lymphadenopathy- absent
Pedal edema- bilateral  grade 2 pitting type














Vitals-
Temperature- Afebrile
BP- 110/70 mm Hg right arm in supine position
PR- 88 bpm, regular rhythm 
RR- 20 cpm thoraco-abdominal.
Spo2 - 94% at room air


Systemic Examination: 

Respiratory system-

Upper respiratory system- 

oral cavity- normal
Nose- normal 
Pharynx- normal 

Lower Respiratory Tract:

Inspection: 

trachea: central 
Shape of chest: Elliptical 
Symmetry of chest  : symmetrical 
Movement: B/L symmetrical expansion of chest respiration
Apex beat- left 5th ICS medial to MCL
No scars, engorged veins or sinuses.




Palpation:

All inspectory findings are confirmed by palpation.
Trachea: central - (confirmed by  three finger test.)
Assessment of anterior and posterior chest expansion- B/L symmetrical expansion of chest.
No chest wall tenderness 
Vocal fremitus- normal




Percussion :
                                  Right               Left

    SCA                 Resonant          Resonant 
    ICA                  Resonant          Resonant     
Mammary          Resonant          Resonant
   IMA                  Resonant          Resonant 
Axillary               Resonant           Resonant
   IAA                   Resonant          Resonant 
   SSA                  Resonant          Resonant Interscapular     Resonant          Resonant
Infrascapular     Resonant          Resonant


Auscultation : 
                               Right               Left 
   SCA                    NVBS              NVBS
   ICA                     NVBS              NVBS 
Mammary             NVBS              NVBS
   IMA                    NVBS              NVBS            Axillary                  NVBS             NVBS
   IAA                    NVBS               NVBS
   SSA                    NVBS              NVBS
Interscapular       NVBS               NVBS
Infrascapular      NVBS                NVBS

Vocal resonance - normal 
Basal crackles are present on both sides 


Cardiovascular System :

Inspection :
No scars sinuses and engorged veins.
No visible pulsations

Palpation:
apical impulse : felt in fifth inter coastal space 

Auscultation:
S1 and S2 heard 
No murmurs 


Per Abdomen:

Inspection:
Shape : elliptical 
Quadrants of abdomen moving in accordance with respiration.
Umbilicus- central and inverted
No scars sinuses or engorged veins 

Palpation:
No tenderness 
No organomegaly

Percussion :
tympanic 

Auscultation:
Normal bowel sounds heard

CNS:
Higher mental functions-normal 
Cranial nerves- intact
Sensory system- normal
Motor system- normal 
Meningeal signs- absent 
Cerebellar signs- absent


INVESTIGATIONS:

CBP  -  reduced Hb

CUE  - albumin in urine

LFT -
   raised ALP
   reduced total protein 
  reduced albumin

RFT - 
     raised urea
     raised cretinine
     raised uric acid and calcium

CXR - 
    Mild cardiomegaly
   Perihilar hazziness
   Air bronchogram appearance 
   Ground glass opacities and interstitial        
       opacities

    
        
USG - 
    Right kidney Grade 2 RPD
    Left kidney Grade 1 RPD



PROVISIONAL DIAGNOSIS :
Chronic kidney disease on Maintenance Hemodialysis with Pulmonary edema

TREATMENT:
Tab.LASIX 40mg BD
Tab.PAN  40mg OD
Tab.NODOSIS  500mg  BD
Tab. OROFER XT   OD
Inj.Erythropoietin 4000 IU/SC
BP,PR,Spo2 monitoring
Salt and fluid restriction 





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