A 45 year old female with SOB

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. I've 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 a diagnosis and treatment plan


Case Report:

A 45 year old female with daily wage labourer by occupation came to opd with chief complaints of:

Generalised body swelling: 2months

Facial puffiness:2months

Shortness of breath:2 hrs


HOPI:

Patient was apparently asymptomatic 6 yrs back one fine day she had giddiness for which she went to a local hospital where she was diagnosed with diabetes and was using OHA since then

1 year later she again felt dizzy & was diagnosed with HTN - on treatment since then

Since last 1 year she started to have pedal edema on & off + bilateral knee pains bcz of which she is not able to do work as usual

4 months back she developed pedal edema, facial puffiness progressed to anasarca, loss of appetite & generalized weakness for which she went to a local hospital in nalgonda where she was diagnosed with renal failure and was given some medication

Fever 2months ago-low grade, intermittent and no diurnal variation

She felt symptomatically better until 10 days back when she again developed anasarca, low back ache & generalized body pains for which she visited our hospital and hemodialysis was advised 

But patient refused and went home due to personal problems

10 days later on 23-04-2023 afternoon hours she was again brought to our hospital with chief complaints of sudden onset SOB since morning

SOB grade-4 associated with orthopnea

No history of chest pain, palpitation, or syncope

No history of fever, cold, or cough

No history of decreased urine output or dysuria


PAST HISTORY:

Patient is k/c/o DM since 6 years and was on OHA (T.GLIMIPERIDE 1mg + METFORMIN 500mg OD)

K/c/o HTN since 5 years and was on treatment (T.ATENOLOL 50mg OD)

No h/o CAD, CVA, Asthma, TB, or Epilepsy



FAMILY HISTORY:

hypertension and diabetes-Mother


PERSONAL HISTORY:


Wakes at 6am,goes to work at 9 am & works in the field for 7 to 8 hrs,returns home at 6-7 pm, goes to sleep at 10pm


Mixed diet & decreased appetite

Sleep adequate

No bowel and bladder disturbances

No addictions


GENERAL EXAMINATION : 


Patient was conscious, coherent & cooperative

Oriented to time, place & person

Heavily built & nourished

Pallor -present 

Pedal edema- present  b/l pitting type extending upto shin of tibia

No icterus, cyanosis, clubbing, koilonychia, lymphadenopathy



VITALS:

Pulse rate -92 beats/min

BP- 190/110 mmHg in both arms  

RR- 28 cpm

SpO2- 78% on RA - 92% on 12 lit O2

GRBS- 168 mg/dl


SYSTEMIC EXAMINATION:


CARDIOVASCULAR SYSTEM:


Inspection: 

Chest is bilaterally symmetrical 

No precordial bulge

Apex impulse visible in 6th intercostal space at midclavicular line 

No visible pulsations, sinus, scars, or dilated veins.


Palpation: 

All inspection findings are confirmed 

Apex impulse - felt in 6th intercostal space at midclavicular line 

No parasternal heave 

No palpable thrills


Auscultation: 

Mitral area - S1 and S2 heard, no murmurs

Aortic area - S1 and S2 heard ,no murmurs

Pulmonary area - S1 and S2 heard ,no murmurs

Tricuspid area - S1 and S2 heard ,no murmurs



RESPIRATORY SYSTEM:

Inspection:

Chest is elliptical & bilaterally symmetrical

Trachea appears to be central

Movements appear to be equal on both sides

No visible pulsations, sinus, scars, or dilated veins.


Palpation:


All inspection findings are confirmed

Trachea central

Movements equal on both sides

Transverse diameter > Antero-posterior diameter 

Apex beat felt in 6th intercostal space at midclavicular line 

Tactile vocal fremitus: equal on both sides in all areas

Percussion:

Resonant note heard in all areas

Auscultation:

Bilateral air entry present

Normal vesicular breath sounds were heard

Fine crepts heard bilaterally in mammary, infra mammary, axillary, infra axillary & infra scapular areas


                                Right              Left 

Supraclavicular     NVBS             NVBS

Infraclavicular       NVBS             NVBS

Mammary                 Fine  Crepitations           

Inframammary          Fine Crepitations 

Axillary                       Fine Crepitations

Infraaxillary             Fine Crepitations  heard              

Suprascapular        NVBS              NVBS

Infrascapular           Fine Crepitations heard   


PER ABDOMEN:

Obese abdomen

Midline inverted umbilicus

LSCS scar + over lower abdomen

No visible pulsations/engorged veins/sinuses

Soft, non-tender, no organomegaly, no free fluid

Bowel sounds present


CENTRAL NERVOUS SYSTEM:

HMF - Intact          

                                                         R.         L.

MOTOR SYSTEM: Power:      UL 4/5      4/5

                                                   LL  4/5      4/5

TONE - Normal.

REFLEXES -   B.    T.    S.     K.    A.   P.

               R.     +2  +2.  +1.   +2.   --.  Flexion.

               L.     +2. +2.  +2.   +2.   --.  Flexion.

CRANIAL NERVES - Normal.


Provisional diagnosis:

This is a known case involving renal system probably chronic kidney disease since 4months 

Type 2 diabetes since 6years and hypertension since 5years 

There is severe anemia secondary to chronic kidney disease.

left heart failure(symptoms suggestive Shortness of breath associated with orthopnea)


Investigations:




USG:



ECG:


Chest x-ray



On 23/4/23








On 24/4/23





25/4/2023

SOB decreased

Edema decreased

Appetite improved

No other complaints 


Patient is c/c/c 

Temp:- 98.4° F 

PR- 78 bpm

RR- 20 cpm

BP- 160/90mmHg

Spo2- 95% at room Air 

GRBS- 135 mg/dl

Input- 500 ml

Output- 300ml


CVS- s1s2 present, no murmurs heard

RS- B/L air entry present, NVBS heard

Fine crepts in b/l infra axillary & infra scapular areas

PA- soft, NT

CNS- NFND


Hemodialysis

Diuresis & other supportive care

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