Case History for final practical examination

A 65 year old female from Alingapuram Came to opd 25 days back with complaints of fever & swelling in bilateral lower limbs since 1 week and Shortnessof breath since 4 days

History of present illness:

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

SOB ( shortness of breath )-  while sitting and was insidious in onset, gradually progressive ( Grade IV )

Swelling in the legs- started  bilaterally in the feet and gradually progressed upto mid calf level ( Grade 2 ) associated with cough.

Associated with fever which is of low grade and continuous type 

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 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:

Shape of chest - normal

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- decreased in inframammary , infra axillary and infra scapular

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 - markedly diminished over the fluid area 

Basal crackles are present.

 Cardiovascular System :

Inspection :

• No scars sinuses and engorged veins
• No visible pulsations

Palpation:

• apical impulse : palpable in fifth inter coastal space 

Auscultation:

• S1 and S2 heard 

• No murmurs 

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 

• Cerebellar signs- absent and meningeal signs are 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

               

X-Ray 

Ultrasound

• few subcentrimetric anechoic cyst in b/l kidneys 

• Rt kidney- CMD lost. Grade III RPD
• Lt kidney- CMD partially maintained. Grade II RPD

ECG

Interpretation of ecg : 

Rate - 100b/min

Normal sinus rhythm

Normal axis

P-wave ,qrs complex , t wave , pr interval ,st segment all  appears to be normal.

Provisional Diagnosis: Renal failure with bilateral pleural 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