Long case for Practical Examination

IP NO. 202109713

A 65 year old female from Alingapuram came to the OPD  25 days back with chief complaints of shortness of breath and swelling in both the legs 

HOPI: 

The patient was apparently asymptomatic 25 days ago when she developed:

SOB- she developed it while sitting and was sudden in onset, gradually progressive

 ( Grade IV )

Edema- started as b/l pedal edema and gradually progressed upto mid calf level

 ( Grade 2 ) associated with cough and fever.

Fever was low grade, continuous type. Relieved on medication.

No H/o chest pain , palpitations, decreased urine output , blood in urine, burning micturition.

Past History: 

No history of similar complaints in the past.

Patient is a known case of Hypertension since 2 years for which she took medication irregularly. 

Not a known case of Diabetes Mellitus, Asthma, TB, Epilepsy 

H/o b/l knee pain since 1 year for which she was prescribed pain killers ( mostly NSAIDS )

No significant surgical history.

Family History: Not significant 

Personal History:

Diet: mixed

Appetite : decreased  

Sleep: reduced

Bowel and Bladder: regular  

Addictions: none

Drug History: No known drug allergies.

General Examination: 

The patient conscious, coherent, not co-operative.

Moderately built, moderately nourished.

Pallor- present 

Edema- pitting type edema

(grade II ) involving both  feet and legs upto mid calf.

Icterus- absent 

Cyanosis : absent

Clubbing : absent 

Koilonychia: absent 

Lymphadenopathy: absent

Vitals:

Temperature: afebrile 

Pulse Rate: 82 beats/min

Blood pressure: 130/ 80 mm hg 

Respiratory Rate: 20 cycles/min

Spo2: 98%

Systemic examination:

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	Stony Dull	Stony Dull
Axillary	Resonant	Resonant
Infraaxillary	Stony dull	Stony dull
Supra scapular	Resonant	Resonant
Interscapular	Resonant	Resonant
Infrascapular	Stony dull	Stony dull

Auscultation:

	Right	Left
Supraclavicular	NVBS	NVBS
Infraclacicular	NVBS	NVBS
Mammary	NVBS	NVBS
Inframammary	Diminished	Diminished
Axillary	NVBS	NVBS
Infraaxillary	Diminished	Diminished
Supra scapular	NVBS	NVBS
Interscapular	NVBS	NVBS
Infrascapular	Diminished	Diminished

Vocal resonance: decreased over the basal areas 

Basal crackles are present

Cardiovascular System :

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

CNS:

• Higher mental functions-normal 
• Cranial nerves- intact
• Sensory system- normal
• Motor system- normal 
• Meningeal signs- absent 
• Cerebellar signs- absent

Investigations:

1. Complete blood picture

• Hb 6.2 g/dl

2. Complete Urine examination 

• albumin +2

3. Liver function Tests:

4. RBS: 82 mg/dl

5. Renal function Tests:

• Raised urea- 94 mg/dl
• Raised creatinine- 6.3 mg/dl
• Raised uric acid - 9.9 mg/dl

6. X-Ray 

7. Ultrasound 

• few subcentrimetric anechoic cysts in b/l kidneys 
• Rt kidney- CMD lost. Grade III RPD
• Lt kidney- CMD partially maintained. Grade II RPD

8. ECG:

Interpretation of ECG:

• Rate- 100 beats/ min

• Normal sinus rhythm 

• Normal axis

• p wave, qrs complex, t wave, pr interval, st  segment - all appear to be normal 

Provisional Diagnosis:

Kidney failure with bilateral plueral effusion

Treatment History:

• Inj piptaz 2.25 g iv TID

• TAB Lasix 40 mg PO/ BD

• TAB Nodosis 500 mg PO/BD

• TAB Orofer  XT PO/OD

• TAB Shelcal CT PO/OD

• Inj  Erythropoietin 4000 IU SC- twice weekly 

     

• Salt and fluid Charting 
• Vitals monitor and strict input/output charting.

Dialysis: 

Patient underwent 6 sessions of dialysis since admission