A 60 YEAR OLD FEMALE WITH SHORTNESS OF BREATH (PRE FINAL EXAMINATION)

This is an online e-log book to discuss our patient de-identified health data shared after taking his / her / guardian's signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.

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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 coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.

MED CASE:- 

A 60-year-old female patient who was a retired weaver by occupation ( stopped 2 years ago )

came opd to the 

Date of examination 2/1/23

CHIEF COMPLAINTS:-

Pedal edema for 3 months 

Shortness of breath for 5 days

HISTORY OF PRESENTING ILLNESS:-

the patient was apparently asymptomatic 9 years back then she felt dizzy and went for a general check-up where she was diagnosed with Hypertension and Type 2 diabetes mellitus.

She is using medication since then

Hypertension ( Amlodipin 5mg 1-x-1; indication :- hypertension; side effects:- nil)

Diabetes ( Inj. Mixtard 20 U -x- 10 U )

5 years back she had frequent episodes of dizziness associated with vomiting which is nonprojectile in nature and associated with photophobia no history of fever; single-sided headache; or meningeal signs 

No history of abdominal distension; colicky pain

Constipation; diarrhoea 

Which was treated locally by a regional practitioner with injection( name unknown)

But these episodes recurred for a duration of 5-6 days.

Then she was taken to our institute diagnosis unknown And was in the hospital for 6 days and was discharged with the medication 

Clopidogrel 75 mg ; beta histine (BD) ; Aspirin

Since 3 months she has had bilateral pedal edema with grade 4 gradual progressive till thighs of the patient.

For the past 5 days, she has had a complaint of shortness of breath which is of grade 4 and is associated with sweating and palpitations.

There has been decreased urinary output for 5 days and lower backache 

No history of cough; fever 

Where local treatment was taken but not got relieved so referred to a higher Center where routine investigations were done to find pericardial effusion and grade 2 RPD changes 

And was referred to our hospital for further management.

PAST HISTORY:- 

No similar complaints in the past 

DM since 9 yrs; HTN since 9 yrs

Not a known case of thyroid, TB, Asthma 

No history of surgeries in the past

PERSONAL HISTORY:- 

Diet - mixed 

Appetite normal 

Sleep - adequate 

Bowel - regular; decreased urinary output

Addictions - occasionally alcohol before 9 yrs

FAMILY HISTORY:- 

no significant family history 

ALLERGIC HISTORY:- 

no allergies to any kind of drugs or food items

GENERAL EXAMINATION:- 

A 60-year-old female patient, supine decubitus who Is conscious, coherent, and cooperative 

comfortably seated/lying on the bed, well-oriented to time,

place and person; well built and well nourished 

 

Pulse:  85 bpm

Rate, rhythm(regular)character(normal ), volume - normal 

peripheral pulsations [Carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis]- present 

no radio radial delay 

BP: 120/80 mm Hg measured on Rt Upper arm In the supine position

Respiratory Rate:25 CPM; 

type- thoracic abdominal 

There is pallor - 

                                

Pedal edema present

                            

No, Icterus, cyanosis, clubbing 

generalized lymphadenopathy 

SYSTEMIC EXAMINATION:-

                    

CVS:-   

INSPECTION:-

Appears normal in shape

Apex beat is not visible

PALPATION:

1- All inspector findings were confirmed.

2-Trachea is central.

3-Apex Beat - diffuse 

 No palpable murmurs (thrills)

AUSCULTATION:-

S 1; S 2 heard in all the areas

CNS examination:-

State of consciousness: conscious

Speech: coherent 

SENSORY SYSTEM:- 

Pain - Normal 

Touch- fine touch - normal

crude touch - normal

Temp - normal

Cranial nerves: Normal

REFLEXES:-

In both the limbs 

Biceps + +

Tricep s + +

Supinator + +

Knee +

Ankle. ++

Felxion:-plantar 

PER ABDOMEN:- 

no tenderness

no palpable organs

bowel sounds - present

RESPIRATORY SYSTEM:-

Bilateral airway entry - present

Normal vesicular breath sounds are heard all over the chest.

Provisional diagnosis:- 

CHRONIC KIDNEY DISEASE; IRON DEFICIENCY ANEMIA WITH DM; HTN SINCE 9 years WITH CVA HISTORY 

INVESTIGATIONS:- 

Before coming to the hospital 

       

29-12-22

         

30-12-22

31-12-22

           

DIAGNOSIS:- 

CHRONIC KIDNEY DISEASE  SECONDARY TO DIABETIC NEPHROPATHY; IRON DEFICIENCY ANEMIA GRADE 1 FATTY LIVER WITH DM; HTN SINCE 9 years WITH HISTORY OF CVA

TREATMENT:-

Inj. Lasix 40mg IV Tid

Tab.Nodosis 500mg Po BD

Tab. amlong 5mg Po BD

Inj. HAI S.C According to GRBS 

GRBS 6th h... before meal

Tab. clopitab-A (75/20) po

Tab.Shelcal po OD

Tab. OrofexXT po OD

Cap. BIO - D3 po OD