55 Yr Old female with Shortness of breath and bilateral pedal edema

FINAL MBBS PRATICAL EXAMINATION: SHORT CASE

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M Tharun Kumar 

Hall ticket no: 1701006115

I've 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 a diagnosis and treatment plan.  

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

Chief complaints:

Shortness of breath Since 2 days 

Bilateral pedal edema since 2 days 

Decreased urine output since 2 days 

History of presenting illness: 

Patient was apparently asymptomatic 6 years back and then she developed bilateral pedal edema for which she visited hospital and diagnosed with hypertension and renal failure

And was on conservative management. Now she presented with Shortness of breath since 2 days which is of grade 4 (According to MMRC grading) and not associated with chest pain and sweating, nausea and vomiting.

Bilateral pedal edema since two days which is of 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 Asthma, Tuberculosis, epilepsy,CAD.

                                  

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 

Pedal Edema  present

 

Pedal edema

Vitals

Pulse rate -106bpm

Blood pressure - 160/80mmHg

Respiratory rate - 34 cpm 

SpO2 92 at room air 

Temperature afebrile 

Systemic examination

Patient examined in sitting position.

Respiratory system:

Inspection:

No tracheal deviation 

Chest bilaterally symmetrical

Type of respiration:  thoraco abdominal.

No dilated veins,pulsations,scars, sinuses.

No drooping of shoulder.

Palpation:

No tracheal deviation

Apex beat- 5th intercoastal space,medial to midclavicular line.

Tenderness over chestwall- Absent.

Vocal fremitus- normal on both sides.

Percussion:                   

Supraclavicular            

Infraclavicular.         

Mammary

Axillary

Infraaxillary

Suprascapular

Infrascapula

Interscapular

Right side and left side- resonant in above areas.

Auscultation:

 Bilateral Basal crepitations heard 

 Diffuse wheeze also present

Cardiovascular system:

Auscultation: 

Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard. 

No murmurs

No thrills

Abdominal examination:

Abdomen shape - Scaphoid, umbilicus- inverted

Soft,  No tenderness.

All quadrants of abdomen area moving normally

Palpation 

Liver not palpable

Spleen not palpable 

Bowel sounds heard on auscultation 

Investigations  

10/06/2022

 

 

 

HbsAg.             

Hiv serology - Negative

11/06/2022 

 

Chest Xray

 

Ultrasound ;

Provisional Diagnosis: 

Chronic kidney disease with Pulmonary edema

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