Short case final practical exam

 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 


Chief complaints :

Abdominal pain 2 days  
Facial puffiness and pedal Edema since 2 days 
Shortness of breath since 2 days 

History of presenting illness :


Patient was asymptomatic 7 months back and she developed facial puffiness and bilateral leg swelling which was pitting in type 

Shortness of breath : 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 was started suddenly and burning type of pain  in epigastric region 

Past history 
She is a/k/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 

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:


Respiratory system:


Patient examined in sitting position

Inspection:-

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

Respiratory movements : bilaterally symmetrical  and reduce

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 5 thICS, 

Respiratory movements bilaterally symmetrical 

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

PERCUSSION

DULL IN BOTH SIDESIN


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- dull


AUSCULTATION:  bowel sounds heard








USG:




ECG:

















PROVISIONAL DIAGNOSIS:

 CKD ON MHD


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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