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