1701006103 CASE PRESENTATION
LONG CASE
Chief complaints:
Shortness of breath Since two days
Bilateral pedal edema since two days
Decreased urine output since two days
History of presenting illness:
No significant past surgical history.
No blood transfusions.
Personal history:
Diet mixed
Appetite normal
Sleep adequate
Bowel regular
Bladder decreased urinary output
No known drug or food allergies
No addictions
Family history:
No significant family history
General examination:
Patient is conscious, coherent and cooperative well oriented to time ,place and person
Well built and well nourished
Pallor present
Icterus absent
Clubbing absent
Cyanosis absent
Generalised lymphadenopathy absent
Edema present
Vitals
Pulse rate 106bpm
Blood pressure 160/80mmHg
Respiratory rate 34 cpm
SpO2 92 at room air
Temperature afebrile
Systemic examination:
Respiratory system:
Patient examined in sitting position
Inspection:
Examined in sitting position
Nose normal
Pharynx normal
Shape of the chest normal
Trachea central in position
Respiratory movements bilaterally symmetrical
Palpation:
No local raise of temperature
All inspectors findings are confirmed
Trachea central in position
Vocal fremitus normal
Percussion:
Resonant
Auscultation:
B/L air entry present
Normal vesicular breath sounds
Bilateral basal crepitations heard
Diffuse wheeze also present
Cardiovascular system:
INSPECTION:
No raised JVP
Chest wall bilaterally symmetrical
Apical impulse seen
Palpation:
Apical beat felt at 5th inter coastal space
No parasternal heave
Auscultation:
S1 S2 sounds heard
No murmurs
No thrills
Abdominal examination:
Shape of the abdomen scaphoid
Umbilicus normal
All quadrants of abdomen area moving normally
No scars sinuses engorged veins
Hernial orifices free
Palpation: soft non tender
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Liver not palpable
Spleen not palpable
Bowel sounds heard on auscultation
Investigations
Serum creatinine
Provisional diagnosis : Chronic kidney disease with pulmonary edema and metabolic acidosis
denovo type 2 diabetes mellitus
Treatment
Dialysis was done after admission.
10/6/22
1)Inj.LASIX 40mg IV/BD
2)tab.NODOSIS 500mg PO/OD
3)tab.MET-XL 25 mg OD
4)tab.AMLONG 10mgOD
5)cap bio-D PO weekly once
6)tab. SHELCAL 500 mg PO OD
7)inj. Erythropoietin 5000 units weekly once
11/6/22
1)Inj.LASIX 40mg IV/BD
2)tab.NODOSIS 500mg PO/OD
3)tab.MET-XL 25 mg OD
4)tab.AMLONG 10mgOD
5)cap bio-D PO weekly once
6)tab. SHELCAL 500 mg PO OD
7)inj. Erythropoietin 5000 units weekly once
8)inj.INSULIN SC according to the GRBS
Chief complaints:
History of presenting illness:
No H/O chest pain palpitations shortness of breath
No H/O of pedal edema
NoH/O decreased urinary output
No H/O seizures
No H/O headache blurring of vision
Past history:
Diagnosed with hypertension during fist pregnancy first pregnancy: intrauterine death at 6th month
She had hyperemesis during first pregnancy in the first trimester
Second pregnancy: baby delivered at 8 th month normal vaginal delivery and died with in one day
Not a known case of diabetes Mellitus, TB, asthma, thyroid disorders , epilepsy
No past surgical history
No blood transfusions done
Menstrual history:
Age of menarche: 13 years
28 day cycle regular bleeds for 3 days
Associated with back ache
Not associated with clots
Marital history:
Married in 2020 non consanguineous
Personal history:
Occupation : house wife
Diet mixed
Appetite normal
Sleep adequate
Bowel and bladder: regular
No addictions
Family history:
Not significant
General examination:
Patient is conscious coherent and cooperative
well oriented to time place and person moderately built and nourished.
Height :161cm
weight:58kg
BMI:22.3kg/m2
No pallor
icterus
cyanosis
clubbing
generalised lymphadenopathy
edema
Vitals pulse rate:90bpm
BP:170/100 mmHg
Respiratory rate:22cpm
Temperature: afebrile
SpO2: 98%
GRBS 164 mg%
Systemic examination:
CVS
Auscultation:S1 S2 sounds heard
no murmurs and
no added sounds
Abdominal examination:
Inspection
Shape scaphoid
Umbilicus inverted
No visible gastric peristalsis
Hernial orifices free
Palpation
soft ,non tender ,no organomegaly
Bowel sounds heard on auscultation
Respiratory system :
Inspection
trachea central in position
Chest movements symmetrical
Auscultation:
BLAE present
NVBS heard
Investigations:
1)tab.AMLONG 5mg PO/OD
2)tab.ZINCOVIT PO/OD
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