58 yr old female with complaints of shortness of breath

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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.

  A 58 year old female resident of munugodu , daily wage labour by occupation Brought to causuality with cheif complaints of shortness of breath since 3 days. 

Complaints of decreased urine output since 10 days Pedal edema since 10 days. 

Patient was apparently asymptomatic 10 years back ,She had leg pains for which she was taking medication ( NSAID) for longer time. 

Later she developed bilateral pedal edema which is initially below the ankle and then progressed to lower limbs .Edema subsided on medication 

She developed shortness of breath 3 days back which is sudden in onset gradually progressive and of grade 4 which is associated with dry cough .She presented to causuality with worsening breathlessness. 

She also noticed facial puffiness since 3 days

No history of chest pain , palpitations. 

History of past illness........ 

She is a known case of hypertension since 6 years

N/k/c/o .DM, TB,Asthma, thyroid abnormalities ,epilepsy

Patient was diagonsed with chickengunya 15 years back for which she was treated

She had similar compaints 10 years back for which she was admitted to private hospital in hyderabad and was diagnosed with chronic kidney disease, was advised to take dialysis but she refused to undergo dialysis( 1 year back)

Later she was diagnosed to be hypertensive for which she is using antihypertensives.. . 

Personal history..... 

Diet : mixed

Appetite: normal

Sleep :disturbed

Bowel movements regular

Burning micturition present

Addictions: none

N/k/c/o food and drug allergies

Treatment history...... 

She is on anti hypertensive drugs and ckd medication for last 7 years

Family history.....

not significant 

General examination...... 

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

Moderately built and nourished

Vitals.... 

PR :75bpm

RR: 16cpm

BP:120/80 mmHg

Temperature: afebrile

Pallor: present

No signs of icterus , cyanosis,clubbing, lymphadenopathy

Bilateral pedal edema : pitting type. 

SYSTEMIC EXAMINATION:

Respiratory system: 

Patient is examined in sitting postion

Inspection: 

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

Chest appears BILATERALY symmetrical and elliptical in shape

Respiratory movements appears equal on both sides and it is abdominothoracic type

Trachea is central in position and nipples in fourth intercostal space 

No dilated veins ,scars,visible pulsations

Palpation: All Inspectory findings are confirmed on Palpation 

Trachea is central in postion. 

Respiratory movements : normal on both sides

Tactile vocal fremitus : increases in INFRAAXILLARY and infrascapular area. 

BASAL Crepitations were heard on the day of admission.

CVS EXAM

S1 S2 heard ++

No murmurs are heard. Apex beat at 6th intercostal space

Cns examination..... 

no focal neurological deficits 

Cranial nerves are intact 

 ABDOMINAL EXAMINATION:

INSPECTION

No distension

• Umbilicus - normal in position

• Equal symmetrical movements in all the quadrants with respiration.

• No visible pulsation ,peristalsis, dilated veins and localized swellings.

•  No scars, sinuses, hernial orifices are seen

PALPATION

• SUPERFICIAL : There is no local rise of temperature 

•     DEEP: no organomegaly 

   

PERCUSSION: tympanic note heard

AUSCULTATION: bowel sounds heard

   

INVESTIGATIONS:

  

Chest x ray :

Increased C:T ratio — cardiomegaly

Obscuration of costophrenic angle. 

2/11/2022.....

3/12/2022....

Usg findings.. 

Bilateral pleural effusion with underlying

Lung collapse. 

4/12/2022  ....... 

5/12/2022....

Provisional diagnosis : 

PROVISIONAL DIAGNOSIS 

• Chronic heart failure with Cardiomegaly and Bilateral pleural effusion 
• Chronic kidney disease 
• severe anemia

TREATMENT: 

 1. INJ LASIX 40mg IV TID

2.T.NODOSIS 250 mg PO TID

3. T.NICARDIA 10mg PO TID

4.T SHELCAL 500mg PO OD

5.CAP BIOD3 PO OD

6.INJ ERYTHROPOIETIN 4000IU,WEEKLY ONCE IV. 

7.INJ OROFERS 100mg IN 100ml,NS IV WEEKLY ONCE.