General Medicine final practicals- long case

 M Kalpana

Hallticket no-1701006110

Batch -2017

This is 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 patients 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 comment box is welcome.

I have 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 diagnosis and treatment plan

55 years old female with shortness of breath

Chief complaints:

55 years old female who is housewife came to the hospital on 10/6/22 with chief complaints of

-Shortness of breath Since 2 days 

-Bilateral pedal edema since 2 days 

-Decreased urine output since 2 days 

Timeline of events:

History of presenting illness: 

Patient was apparently asymptomatic six years back 

Then developed pedal edema  which is bilateral ,for which she visited hospital and diagnosed with hypertension and renal failure

And  on conservative management 

From past 2days,

—patient developed shortness of breath grade 4  sudden in onset,  not associated with chest pain  ,sweating .

No orthopnea & pnd , cough 

—Bilateral pedal edema   which is pitting type 

—Decreased urinary output not associated with        burning micturition 

Past history: 

Known case of hypertension since 6years

Known case of chronic kidney disease since 6 years 

diabetes mellitus type -2( diagnosed after coming to our hospital) — GRBS 418mg%

Not a known case of Asthma,TB ,CAD, epilepsy 

                                 

No history of surgeries in the past

No  history of blood  transfusions.

Personal history:

Diet -mixed 

Appetite -normal

Sleep -adequate 

Bowelmovements-regular

Bladder movements-decreased urinary output since 2days

No known drug or food allergies 

No addictions

Family history:

No significant family history

General examination: 

After taking consent ,patient is examined in well lit room

Patient is conscious, coherent and cooperative well oriented to time ,place and person 

moderately  built and moderately  nourished 

Pallor -present

Icterus -absent 

Clubbing -absent

Cyanosis -absent 

Generalised lymphadenopathy -absent 

Edema  -absent

https://youtube.com/shorts/n1Ypg1Cb1-s?feature=share

Vitals-

(At the time of admission)

Temperature-afebrile

Pulse rate -106 beats per minute ,regular rhythm ,normal volume,normal character ,no radio radial delay

Blood pressure -160/80mmHg measured in left arm in supine position 

Respiratory rate -34 cycles per minute

SpO2- 92 %at room air 

Systemic examination:

Respiratory system:

Upper respiratory system - normal

Examination of chest-

Inspection:

Shape of the chest -normal, bilaterally symmetrical

Trachea -central in position 

Respiratory movements -normal, bilaterally symmetrical

No scars,sinuses, engorged veins seen on chest wall

Palpation:

No local rise of temperature

No tenderness 

All inspectory findings are confirmed

Trachea -central in position

vocal Fremitus - normal 

Chest movements - normal ,symmetrical bilaterally

Percussion:

Resonant note heard

Auscultation: 

Bilateral air entry present

Normal vesicular breath sounds heard

Bilateral basal crepitations  heard

Diffuse wheeze present

Cardiovascular system: 

Inspection- 

No raised JVP

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse at 5th intercostal space

Palpation-

Apex beat is felt in the fifth intercostal space, 1 cm medial to  the midclavicular line

No parasternal heave felt

Percussion-

Right and left borders of the heart are percussed 

Auscultation-

S1 and S2 heard, no added thrills and murmurs are heard 

Abdominal examination:

Inspection-

Shape of the abdomen- scaphoid 

Umbilicus -normal

All quadrants of abdomen area moving normally

Palpation -

No local rise of temperature

No tenderness

Soft ,non tender

Liver not palpable

Spleen not palpable 

Kidney not palpable

Auscultation -

Bowel sounds heard 

Central nervous system examination- 

Higher mental functions -normal

 Cranial nerves-Normal

Sensory and motor examination- normal

Reflexes-normal 

Investigations 

On 10/06/22

Complete blood picture-

Complete urine examination-

Renal function tests-

Arterial blood gas-

Serum electrolytes-

Spot urine sodium -

Urine protein/creatinine ratio-

Liver function tests-

Serum creatinine-

Blood urea-

APTT-


Urine for ketone bodies-

Prothrombin time-

Serology-

Ultrasonography -

On 11/06/22-

Arterial blood gas-

Complete blood picture -

Chest x ray-

ECG:

2D echo-

https://youtube.com/shorts/zS-XjJgm4Bw?feature=share

Provisional diagnosis-

Chronic renal disease with  pulmonary edema and metabolic acidosis with denovo diabetes mellitus type-2

Treatment :

Dialysis was done after admission in the hospital

On 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 

On 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