58 year old female came to OPD with shortness of breath

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CASE REPORT

A 58 year old female came to OPD with shortness of breath.

  

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 10 days back then she developed swelling in the legs which is progressive, pitting in nature and gradually progressed up to the knee, accompanied with facial puffiness.

Patient also had burning micturition and decreased urine output. Then she developed shortness of breath 3 days back. Which was persistent even while resting. (GRADE-4)

No h/o chest pain

No h/o palpitations 

No h/o abdominal pain  

No h/o fever  

No h/o cough

PAST HISTORY

Patient was infected with chickengunya 15 years back and went to a private hospital in hyderabad. She started using pain medication for back pain and joint pains from then.

She has been undergoing treatment for chronic renal failure for the last 6 years.

She is a known case of hypertension for last 5 years.

No h/o diabetes 

No h/o TB

No h/o epilepsy

No h/o asthma 

TREATMENT HISTORY:

Overuse of NSAIDS (pain medications) since 15 years and stopped 5 months ago.

Use of drugs for chronic kidney disease since 6 years.

Use of hypertensive drugs since 5years.

PERSONAL HISTORY:

Appetite: normal

Diet : mixed 

Bowel and bladder: burning micturition and decreased urne output , 

normal bowel movements

Addictions : no addictions 

Sleep: adequate

FAMILY HISTORY:

None of patient’s parents,siblings,relatives have or have had similar complaints or significant co-morbidities.

GENERAL EXAMINATION: 

Patient is consious, coherent and cooperative.

Well oriented to time, place and person. 

Moderately built, moderately nourished. 

 

Pallor is present

Pedal edema present (pitting edema)

No icterus, cyanosis, clubbing, generalised lymphadenopathy.

Pulse: Rate: 72 , rhythm (regular), character (normal), volume ( normal)

no radio radial delay 

BP: 130/80 mm Hg measured on Right Upper arm in supine position

Respiratory Rate: 25 cpm

RESPIRATORY SYSTEM: 

 Patient examined in sitting position

Inspection:-

Upper respiratory tract - oral cavity, nose & oropharynx appears normal. 

Chest appears Bilaterally symmetrical & elliptical in shape

Respiratory movements appear equal on both sides and its Abdominothoracic type. 

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

No signs of volume loss

No dilated veins, scars, sinuses, visible pulsations. 

Palpation:-

All inspiratory findings confirmed

Trachea central in position

MEASUREMENTS-

AP diameter-                  8 inch

Transverse diameter-    12 inches

AP/T ratio - 0.66

Respiratory movement's:- normal on both sides

Tactile vocal fremitus - increased in  Infraaxillary & infra scapular area. 

Percussion:-

                                       Right                     left

Supraclavicular- Resonant (R)                       (R) 

Infraclavicular-              (R)                         (R) 

Mammary-                     dull                       Dull

Axillary-                          (R)                       (R) 

Infra axillary-                Dull                        Dull

Suprascapular-             (R)                          (R) 

Interscapular-               (R)                         (R) 

Infrascapular-              Dull                          dull

Auscultation:-

                                      Right                                     Left

Supraclavicular- Normal vesicular                       NVBS

                        Breath sounds (NVBS) 

Infraclavicular-        NVBS                                 NVBS

Mammary-              NVBS                                 NVBS

Axillary-                  NVBS                                 NVBS

Infra axillary-          NVBS                                 NVBS

                                                          

Suprascapular-        NVBS                                 NVBS

Interscapular-          NVBS                                NVBS

Infrascapular-          NVBS                                NVBS

 

PALPATION:

1. No local rise in temperature 

2. No tenderness

3. All inspector findings confirmed. (Tracheal position, apex beat)

4. Expansion of the chest: equal in all planes 

PERCUSSION:

Resonant all over the chest except mammary and inframammary areas.

PER ABDOMEN:

INSPECTION:

Local rise in temperature.

9 REGIONS

Shape: scaphoid

No Distention of Abdomen 

Flanks: full 

Umbilicus: normal 

The skin over the abdomen: smooth

No engorged veins, visible pulsations, or hernia orifices.

PALPATION: no hepatomegaly no splenomegaly

PERCUSSION: 

Normal

No shifting dullness.

AUSCULTATION: 

Dull bowel sounds heard.

CVS:

INSPECTION:

Appears normal in shape, apex beat not visible 

PALPATION: 

All inspectory findings are confirmed. 

Trachea is central 

No murmurs 

AUSCULTATION 

S1, S2 heard 

INVESTIGATIONS:

2.12.22

3.12.22

Usg findings:

B/L pleural effusion with underlying lung collapse 

4.12.22

PROVISIONAL DIAGNOSIS:

 Chronic kidney disease probably due to NSAIDs abuse with severe anaemia and bilateral pleural effusion.

TREATMENT:

1. Inj. Lasix 40mg IV TID

2.Tab. Nodosis 250mg 

3.Tab. Nicardia 10mg

4.Tab. Shellal 500mg 

5.Cap. BIOD3 

6. Inj. Erythropoeitin 4000IU

Weekly once IV

7.inj. Orofer 100mg IN 100ml

 NS IV weekly once