1601006125 SHORT CASE

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This is an online E log book to discuss our patient’s de-identified data shared after taking his/her/guardian’s signed informed consent.

 A 56 year old female patient  resident of rasalpuram, house wife by occupation,came to the hospital with he chief complaints of  shortness of breath since 1 day.
  Patient was apparently asymptomatic 3months ago then she developed  shortness of breath  of grade 3 and pedal oedema which she was diagnosed as chronic kidney disease  then was given treatment and hemodialysis.

PAST HISTORY

 She visited nalgonda hospital for high grade fever 2years back .
PERSONAL HISTORY
     Diet:mixed
      Appettite : decreased
       Sleep: adeqate
      Bowel and Bladder: regular  
      Addictions: none                          
GENERAL EXAMINATION
 Patient is conscious ,coherent , cooperative. Moderatly build and nourished. 
No pallor, 
no icterus , 
Bipedal oedama which is of pitting type  Grade 3
  https://drive.google.com/file/d/1tYiQN_QUY5JdECqUDvg41qK33dQQZC_2/view?usp=drivesdk
No cyanosis
 No clubbing
No koilonychia
No lymphadenopathy.

Vitals:

Temperature: afebrile 

Pulse Rate: 82 beats/min

Blood pressure: 130/ 80 mm hg 

Respiratory Rate: 20 cycles/min

Spo2: 98%

Respiratory System:


Inspection of upper respiratory system- 

  • oral cavity- normal
  • Nose- normal 
  • Pharynx- normal 

Lower Respiratory Tract:


Inspection: 

  • trachea: central 
  • Symmetry of chest  : symmetrical 
  • Movement: B/L symmetrical expansion of chest respiration
  • No scars, engorged veins or sinuses.

  • Palpation:


    All inspectory findings are confirmed by palpation.

    • Trachea: central - confirmed by  three finger test.
    • Assessment of anterior and posterior chest expansion- B/L symmetrical expansion of chest.
    • No chest wall tenderness 
    • Vocal fremitus- normal 


      • Percussion : done in sitting position 

        


      Right 

      Left

      Supraclavicular

      Resonant 

      Resonant

      Infraclacicular

      Resonant 

      Resonant

      Mammary

      Resonant 

      Resonant 

      Inframammary

      Resonant

      Resonant

      Axillary

      Resonant 

      Resonant 

      Infraaxillary     

      Resonant

       Resonant

      Supra scapular 

      Resonant 

      Resonant 

      Interscapular

      Resonant   

      Resonant 

Auscultation:



Right 

Left

Supraclavicular

NVBS

NVBS

Infraclacicular

NVBS

NVBS 

Mammary

NVBS

NVBS

Inframammary

NVBS

 NVBS

Axillary

NVBS

NVBS 

Infraaxillary.     

NVBS

NVBS

Supra scapular 

NVBS

NVBS 

Interscapular

NVBS

NVBS

Infrascapular

NVBS     NVBS



Inspection :


  • No scars sinuses and engorged veins.
  • No visible pulsations


Palpation:

  • apical impulse : heard in fifth inter coastal space 


Auscultation:

  • S1 and S2 heard 
  • No murmurs 

  • Per Abdomen:


    Inspection:

    • Shape : elliptical 
    • Quadrants of abdomen moving in accordance with respiration.
    • Umbilicus- central and inverted
    • No scars sinuses or engorged veins 


    Palpation:

    • No tenderness 
    • No organomegaly


    Percussion

    • tympanic 

    Auscultation:

    • Normal bowel sounds heard
    INVESTIGATIONS : 

  • Management:

Hemodialysis:through Central Venous Catheter.

Drugs:

Tab.lasix 40mg bd

Tab.nicardia 10mg tid

Tab.shelcal od



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