1701006186 CASE PRESENTATION

 LONG  CASE: 

A 22 year old female patient resident of miryalaguda came with chief complaint of blurring of vision, pedal edema.


History of  present illness 


Patient was apparently asymptomatic 10 months back when she developed blurred vision which was insidious in onset gradually progressive not associated with any aggrevating and reliving factors.
Initially while writing degree final year exa she noticed blurring of vision,for which she visited ophthalmologist where she found to have high blood pressure then based on fundoscopic examination, investigation report doctor refferd her to nephrologist where she was diagnosed with derranged kidney function.
She is undergoing dialogue twice a week.
On prolonged sitting she developed edema in the leg which is of pitting type.

Past history : 


 No history of Bronchial asthma,Diabetes, Epilepsy.

Personal history 

Her appetite is normal 
She takes mixed diet
Her bowel and bladder movements are regular
No known allergies 


Family history 


Her father is a known case of hypertension.


General examination 

Patient is conscious coherent and coperative  ill built and moderately  nourished

Vitals

Temperature Afibrile

Pulse rate 82 bpm

Respiratory rate 18cpm

Bp 110/70mmhg

Spo2 99%in room air





No pallor 
No icterus
No cyanosis
No clubbing

SYSTEMIC EXAMINATION 


Systemic examination:-
-CVS
S1 and S2 are heard
no thrills and no murmurs
-Respiratory 
vesicular breath sounds heard
trachea is in central position
no wheezing
no Dyspnoea
-Abdomen
no tenderness
no palpable mass
no hernial orifices
no free fluid
liver and spleen are not palpable
bowel sounds are heard
-CNS
Conscious and normal speech
normal gait
crainal nerves are normal
sensory system is normal
motor system is normal
INVESTIGATIONS-








Provisional diagnosis :
Chronic kidney disease on hemodialysis. 
TREATMENT given: and
1.Fluid restriction less than 1.5 lit per day
Salt restriction less than 2gm per day
Tablet lasix40 mg po bd
Tab Nicardia 20 mgPo tid
Tab Nodosi  500 mg po bd
Inj erythropoietin 4000Iu sc weekly once

----------------------------------------------------------------------------------------------------------------------

SHORT  CASE: 

A 70YR OLD MALE CAME TO OPD WITH CHIEF COMPLAINTS OF SHORTNESS OF BREATH SINCE 20days. COUGH since 20days

History of present illness::

 SHORTNESS OF BREATH since 20 days which was insidious in onset gradually progressive
Grade 2-3 according to MMRC not associated with orthopnea , paroxysmal nocturnal dyspnoea,no postural and diurnal variation ,relieving on rest,aggrevating on working.

COUGH since 20 days insidious onset ON AND OFF productive with mucoid sputum non foul smelling,not blood stained, no nocturnal and diurnal variation , relieved on medication

No H/o wheez,
chest pain, palpitations
 H/o loss of weight(5kg in last month)
H/o loss of appetite

Past history::

H/o similar complaints in past 10 yrs back 
No H/o Diabetes, hypertension,asthma ,CAD,seizures.

Family history::

 No H/o respiratory diseases in family

Personal history::
 
Diet:mixed
Sleep :: adequate
Appetite:: decreased
Bowel and bladder:: regular
Addictions:: alcoholic since 50 yrs (daily 250 ml whisky)
                      Smoking since 50 yrs( daily 4-5 beedies)
                     Toddy rarely ( daily 1 lt )
Stopped smoking since 10 yrs
Treatment history::

H/o ATT taken previously 10 yrs back
No allergies to drug,food

General examination::

After taking consent patient examined in a well lit room

Patient was conscious coherent cooperative 
Well oriented to time ,place ,person
Thin built, nourishment moderate




Mild pallor
No icterus
No Lymphadenopathy
No cyanosis
No clubbing
No edema
Vitals..
Pulse:102bpm
Bp:130/80 mm of hg
Temperature::afebrile
RR:16c/min

Systemic examination

Respiratory examination

Inspection-

B/L symmetrical and elliptical
Trachea appears to be central
Supraclavicular and infraclavicular hallowing present
Expansion of chest equal on both sides
Expansion of chest normal
No crowding of ribs 
No drooping of shoulder
Wasting of muscles present
No scoliosis ,kyphosis
No sinuses,scars,engorged veins




Palpation-

No local rise of temperature
All inspectory findings confirmed
Trachea central 
Apex beat felt in 5th ICS in mid clavicular line
Vocal fremitus ..right side decrease in IAA area

Percussion-

Direct : over clavicle and manubrium sternum
Indirect :

                                  Right.       Left.

Supraclavicular. Resonant. Resonant
Infraclavicular. Resonant. Resonanat
Mammary. Resonant. Resonant
Inframammary. Resonant. Resonanat
Axillary Resonant. Resonant
Infraaxillary. Dullness. Resonant
Suprascapular. Resonant. Resonant
Interscapular. Resonant Resonant
Infrascapular. Dullness. Resonant

Auscultation-

 B/L air entry present
Normal vesicular breath sounds heard
Decreased breath sounds in Infra axillary Areas,Infra Scapular areas
 Vocal resonance ::decreased in InfraAxillaryArea,InfraScapular area

Per abdomen
Scaphoid
Soft non tender
No organomegaly
Bowel sounds normal
No sinuses scars engorged veins
No palpable mass

Cvs

JVP not raised
S1 S2 heard
No murmurs 

Cns

Conscious 
Speech normal
Cranial nerves ::Normal
Motor system::normal
Sensory system ::Normal


Investigations:::

X-ray chest PA view


Complete blood picture::

 Hemoglobin.8.6gm%
Total leucocyte count 4100
Neutrophils 75%
Lymphocytes 15%
Monocytes 06%
Eosinophils 04%
Basophils 0%
Platelet count 2.45lakh/mm3

Cue:normal 

Liver function tests::
Total bilirubin:0.43 mg/dl
Direct bilirubin:0.14 mg/dl
AST:23 U /L
ALP:165 U /L
ALT:11 U /L
TP:6.7g/dl
A/G:0.89

Renal function tests::

Urea:33 
Creatinine:1.2 mg/dl
Uric acid:5.6 mg/dl

Serum electrolytes::

Na+::133 mEq/L
K+::4.2 mEq/L
Cl-::45 mEq/L

Provisional diagnosis-

 Right sided Pleural effusion
Pantoprazole iv 40mg(lyophilized)
Mucinac 600
Amoxycillin and potassium clavulanate iv 1.2gm
Brodex T 100ml

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