Final Practical Long case



1701006032 CASE PRESENTATION 

LONG CASE :

A 30 year old female patient who is house wife by occupation resident of Nalgonda came to OPD with chief complaints of 

Chief complaints :
  
Facial puffiness and pedal Edema since 2 days 
Shortness of breath since 2 days 
Abdominal pain since 2days 

History of presenting illness :

Patient was asymptomatic 7 months back and she developed facial puffiness and bilateral leg swelling which was pitting in type 
SOB: insidious in onset gradually progressed to grade 4 not associated with change in position no aggravating and relieving factors 
Abdominal pain : pain in epigastric region
since 2days which was started suddenly and burning type of pain 



Past history 
She is a known case of hypertension since 12 years 

Personal history :

Appetite : decreased 
Diet : mixed 
Sleep : inadequate 
Bladder : decreased urine output
Bowel movements: normal 
Addictions :absent 
 
Family history:
Patients mother is hypertensive 

General examination:

Pallor: present 
Icterus: absent 
Cyanosis : absent 
Clubbing : absent 
Lymphadenopathy : absent 
Edema : absent 







Vitals:
 Temperature: a febrile
 Pulse: 120 bpm
 Blood pressure: 150/90mmHg 
 Respiratory rate : 34 cpm

Systemic examination:

Respiratory system:

Patient examined in sitting position

Inspection:-
oral cavity- Normal ,nose- normal ,pharynx-normal 

Respiratory movements : bilaterally symmetrical 

Trachea is central in position & Nipples are in 4th Intercoastal space

Apex impulse is not visible 



Palpation:-
All inspiratory findings are confirmed
Trachea central in position
Apical impulse in left 6th ICS, slightly lateral

Respiratory movements bilaterally symmetrical 

Tactile and vocal fremitus reduced on both sides  in infra axillary and infra scapular region , mammary regions

PERCUSSION

DULL IN BOTH SIDES


AUSCULTATION :
DECREASED BREATH SOUNDS ON BOTH SIDES

Cardiovascular system 
JVP -raised
Visible pulsations: absent 
Apical impulse : shifted downward and laterally 
Thrills -absent 
S1, S2 - heart sounds muffled 
Pericardial rub -present 



Abdomen examination:

INSPECTION

Shape : distended 
Umbilicus:normal 
Movements :normal
Visible pulsations :absent 
Skin or surface of the abdomen : normal 

PALPATION
Liver is not palpable

PERCUSSION : Dull 

AUSCULTATION :bowel sounds heared 


INVESTIGATONS

Chest x-ray:




USG:



ECG:


















PROVISIONAL DIAGNOSIS:

Chronic kidney disease on maintainance hemodialysis 
Ascites 

Treatment:

INJ. MONOCEF 1gm/IV/BD
INJ. METROGYL 100ml/IV/TID
INJ PAN 40mg/IV/OD
INJ. ZOFER 4mg/iv/SOS
TAB. LASIX 40mg/PO/BD
TAB. NICORANDIL 20mg/PO/TID
INJ. BUSOCOPAN /iv/stat 

Add on
TAB. OROFENPO/BD
TAB. NODOSIS 500mg/PO/TID
INJ.EPO 4000 ml/ weekly 
TAB. SHELLCAL/PO/BD 
DIALYSIS (HD)
INJ.KCL 2AMP IN 500 ml NS over 5min








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