Final practical short case

 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.



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 2 days
Facial puffiness and pedal Edema since 2 days 
Shortness of breath since 2 days 
 Timeline :






History of presenting illness :

Patient was asymptomatic 12 months back and 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 2 days which started suddenly and burning type of pain 
In epigastric region 
No aggravating and reliving factors

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: regular 
Addictions :absent 
 
Family history:
Patients mother is hypertensive 

General examination:

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

Vitals:
 Temperature: a febrile 
 Pulse: 120bpm
 Blood pressure:150/90 mm of hg
 Respiratory rate : 34 bpm

Systemic examination:

Cardiovascular system  


JVP -raised
Visible pulsations: absent 
Apical impulse : shifted downward and laterally 6th intercostal space
Thrills -absent 
S1, S2 - heart sounds muffled 
Pericardial rub -present 

Respiratory system:

Patient examined in sitting position

Inspection:-
oral cavity- Normal ,nose- normal ,pharynx-normal 
Shape of chest - normal
Chest movements : bilaterally symmetrically reduced

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

Palpation:-
All inspiratory findings are confirmed
Trachea central in position
Apical impulse in left 6th left ICS, 

Chest movements bilaterally symmetrical reduced

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

PERCUSSION:
Dull on both sides


AUSCULTATION DECREASED ON BOTH SIDE 
bronchial sounds are heared -reduced

Abdomen examination:

INSPECTION

Shape : distended 
Umbilicus:normal 
Movements :normal
Visible pulsations :absent
Skin or surface of the abdomen : normal 

PALPATION
Liver is not palpable 

PERCUSSION- dull

AUSCULTATION :bowel sounds heard



















PROVISIONAL DIAGNOSIS:

 CKD on multiple hemodialysis

Treatment:

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

Add on
TAB. OROFER PO/BD
TAB. NODOSIS 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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