1701006085 CASE PRESENTATION
LONG CASE
A 40 yr old female patient who is a daily wage worker came to the OPD with the CHEIF COMPLAINTS of
Abdominal Distension since 1 year
Facial puffiness since 1 year
Itching all over the body since 1 year and developed multiple plaques on abdomen and Lower limbs
Sob since 5 days
pedal edema since 5 days pitting type
TIMELINE OF EVENTS
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 1 year back then she developed abdominal distension , associated with abdominal discomfort- diffuse abdominal pain — which was aggravated after eating , releived on sleeping/ taking rest , sitting & after defecation .
facial puffiness,itching all over the body &
5 days ago she developed :
pedal edema and SOB grade 3.
PAST HISTORY
* She developed B/L Knee pain - since 3years, onset - insidious, gradually progressing, type- pricking, non radiating , more at the night, aggravated on walking, relieved on sitting and sleeping & on medication.
No history of trauma. No history of fever swelling in the knees during the pain
* She developed abdominal distension and facial puffiness one year back
* She is diagnosed with (itching skin lesions)— tinea corporis since 1 yr amd she is put on medication for it.
MEDICAL HISTORY:
* She is under medication( demisone 0.5 mg and acelogic SR) since 3 yrs
DIET : Mixed
APPETITE : Decreased
SLEEP : Normal
BOWEL AND BLADDER HABITS : decreased urine output
ADDICTIONS: No
GENERAL EXAMINATION
* Patient is concious coherent and coperative, well oriented to time palce and person
VITALS
Blood pressure : 110/80
Pulse Rate : 90bpm
Temperature : 98.5degrees F
SPO2 : 98 @ RA
GRBS : 106
* NO PALLOR , ICTERUS , CYANOSIS, CLUBBING , LYMPHADENOPATHY
RESPIRATORY SYSTEM EXAMINATION :-
Inspection-
2D echo :
30 years old female, who is HOUSEWIFE by occupation resident of nalgonda
came to the opd with the CHEIF COMPLAINTS:
* Abdominal pain since 7 days
* shortness of breath since 4 days
* pedal edema since 4 days
* facial puffiness since 4 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 12 months back then she developed;
* Abdominal pain : pain since 7 days which started suddenly and burning type of pain In epigastric region No aggravating and reliving factors
* Breathlessness:
shortness of breathe since 4 days which is of grade 4 and associated with profuse sweating.
SOB: insidious in onset gradually progressed to grade 4 not associated with change in position no aggravating and relieving factors
* Pedal edema:
She complaints of pedal edema since 4 days which is of pitting type. She had similar edema episodes before this one month which were resolving and reappearing and this time it is not resolved for 1 month.
* She also developed facial puffiness
TIME LINE OF EVENTS :
* No history of FATIGUE
* No history of COUGH, HAEMOPTYSIS
* No history of DYSPHAGIA, HOARSENESS OF VOICE
* No history of HIGH ARCHED PALATE, CHEST DEFORMITY
* No history of RECURRENT RESPIRATORY TRACT INFECTIONS, FEVER, SORE THROAT, CLUBBING, SPLINTER HAEMORRHAGE
* No history of FEVER, JOINT PAINS
PAST HISTORY:
* She is diagnosed as Gestational HYPERTENSION 12 years back for first pregnancy (after 4th child she discontinued use of anti hypertensive drugs)
* She is a not a known case of diabetes, asthma, epilepsy, hyperthyroidism, COPD
* No history of blood transfusion
* No history of allergy
MARTIAL HISTORY:
* Age of menarche 12 year
* Age of marriage 18 years
* It is a nonconsanguinous marriage
* She has 4 children
— ( in 2011 first child(girl )- normal vaginal delivery -diagnosed as HYPERTENSION
— In 2012 second child(girl)- normal vaginal delivery
— In 2014 third child(girl) - normal vaginal delivery
— In 2015 fourth child(girl)- normal vaginal delivery -she also had episode of Dyspnea of grade 3 (not get attention to symptoms)
FAMILY HISTORY:
father and mother are known case of HYPERTENSION since 6years
PERSONAL HISTORY:
DEIT: mixed
APPETITE: loss of appetite
BOWEL :normal
BLADDER: DECREASED URINE OUTPUT
SLEEP: INadequate
ADDICTIONS: no addictions
GENERAL EXAMINATION:
A 30 year old patient, who is moderately built and well nourished is CONSCIOUS, COHERENT, COOPERATIVE, AND COMFORTABLY LYING ON BED, well oriented to TIME, PLACE AND PERSON.
THERE IS PALLOR
NO icterus
NO cyanosis
No koilonychias
No generalized lymphadenopathy and
No pedal edema
Vitals:
Temperature: a febrile
Pulse: 92/ min
Blood pressure: 150/90 mmHg
Respiratory rate : 34 cpm
SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM:
Patient examined in sitting position
INSPECTION
oral cavity- Normal ,nose- normal ,pharynx-normal
Shape of chest - normal
Chest movements : bilaterally symmetrically reduced
Trachea is central in position & Nipples are in 4th Intercoastal space
APEX IMPULSE VISIBLE IN 6TH INTERCOASTAL SPACE
PALPATION
All inspiratory findings are confirmed
Trachea central in position
Apical impulse in left 6 thICS,
Chest movements bilaterally symmetrical reduced
Tactile and vocal fremitus REDUCED on both sides in infra axillary and infra scapular region
PERCUSSION
DULL IN BOTH SIDES in infra axillary and infra scapular region
AUSCULTATION
DECREASED ON BOTH SIDE in infra axillary and infra scapular region
BRONCHIAL sounds are heared -REDUCED
CARDIOVASCULAR SYSTEM :
JVP -raised
Visible pulsations: absent
Apical impulse : shifted downward and laterally 6th intercostal space
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 heard
INVESTIGATIONS :
HIV TEST
HBSAG
CBP
BLOOD GROUPING
RFT
SERUM IRON
ECG
BACTERIAL CULTURE
X RAY :
2D ECHO
DIAGNOSIS:
A CASE OF KNOWN HYPERTENSION
A CASE OF CHRONIC KIDNEY DISEASE ON MAINTENANCE OF HEMODIALYSIS
HEART FAILURE MAY BE SECONDARY TO CKD
PLEURAL EFFUSION & PERICARDIAL EFFUSION secondary to HF AND CKD ( fluid overload)
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. OROFER PO/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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