Final examination long case

 I 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. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box

1701006018

30year old female with facial puffiness and pedal edema.


A 30 year old female patient who is house wife by occupation resident of Nalgonda came to OPD with chief complaints of 
  
Abdominal pain since 2days 
Facial puffiness and pedal Edema since 2 days 
Shortness of breath since 2 days 

History of presenting illness :

Patient was asymptomatic 7 months back
She developed facial puffiness and bilateral leg swelling which was pitting in type 
SOB: insidious in onset 
          gradually progressed to grade 4 
          not associated with change in position 
          no aggravating and relieving factors 
Abdominal pain : pain since 7 days which was 
                            started suddenly and 
                            burning type of pain




Past history 
She is a known case of hypertension since 12 years 

Personal history :

Appetite : decreased 
Diet : mixed 
Sleep : inadequate 
Bladder : decreased urine output
Bowel movements: normal 
Addictions :absent 
 
Family history:
Patients mother is hypertensive since 5years

General examination:

Pallor: present 
Icterus: absent 
Cyanosis : absent 
Clubbing : absent 
Lymphadenopathy : absent 
Edema : absent














Vitals:
 Temperature: a febrile
 Pulse: 120 bpm
 Blood pressure: 150/100 mmHg 
 Respiratory rate : 34 cpm

Systemic examination:

Respiratory system:

Patient examined in sitting position

Inspection:-

oral cavity- Normal ,nose- normal ,pharynx-normal 

Respiratory movements : bilaterally symmetrical 

Trachea is central in position & Nipples are in 4th Intercoastal space

Apex impulse visible in 6th intercostal space

Palpation:-

All inspiratory findings are confirmed

Trachea central in position

Apical impulse in left 6th ICS, 

Respiratory movements bilaterally symmetrical 

Tactile and vocal fremitus reduced on both sides  in infra axillary and infra scapular region

PERCUSSION

DULL IN BOTH SIDES


AUSCULTATION DECREASED ON BOTH SIDE in above areas

bronchial sounds are heared 

Cardiovascular system :

JVP -raised

Visible pulsations: absent 

Apical impulse : shifted downward and laterally 

Thrills -absent 

S1, S2 - heart sounds muffled 

Pericardial rub -present 

Abdomen examination:

INSPECTION

Shape : distended 

Umbilicus:normal 

Movements :normal

Visible pulsations :normal 

Skin or surface of the abdomen : normal 

PALPATION

Liver is palpable 

PERCUSSION

AUSCULTATION 



INVESTIGATONS

X-Ray:





USG:










ECG:













PROVISIONAL DIAGNOSIS:

 CKD on MHD
(Chronic kidney disease on maintainance hemodialysis)
Treatment:

INJ. MONOCEF 1gm/IV/BD
INJ. MGTILOGYL 100ml/IV/TID
INJ PAN 40mg/IV/OD
INJ. ZOFER 4mg/iv/SOS
TAB. CASIX 40mg/PO/BD
TAB. NICORANDIL 20mg/PO/TID
INJ. BUSOCOPAN /iv/stat 

Add on
TAB. ONOFER PO/BD
TAB. NODOSH 500mg/PO/TID
INJ.EPO 4000 ml/ weekly 
TAB. SHELLCAL/PO/BD 
DIALYSIS (HD)
INJ.KCL 2AMP IN 500 ml NS over 5min



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