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58 year old female came to OPD with shortness of breath

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 solveb 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 is welcome.

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





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