Long case - Final MBBS Practical examination

Long case - Final MBBS Practical examination

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-centered online learning portfolio and your valuable inputs on the comment box.


A 30 year old female patient, who is a housewife and resident of Nalgonda came to OPD with chief complaints of:- 

Puffiness in face and pedal edema since 2 days.
Shortness of Breath since 2 days.
Abdominal pain since 2 days.

History of presenting illness:-

Patient was apparently asymptomatic 7 months ago, then she developed facial puffiness and B/L leg swelling which was pitting in nature.
Shortness of breath which is insidious in onset, gradually progressed to grade 4, not affected with change in position, no aggravating and relieving factors.
Abdominal pain: epigastric pain since 7 days which started suddenly and burning type of pain.

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

Personal history:
Diet - mixed 
Appetite - Decreased
Sleep - Inadequate 
Bladder - Decreased urine output
Bowel movements - normal 
No addictions.
 
Family history:
Patient mother is a hypertensive .

General examination:
Pallor - present 
Icterus - absent 
Cyanosis - absent 
Clubbing - absent 
Lymphadenopathy - absent 
Edema - absent 



Vitals:
 Temperature - Afebrile
 Pulse - 110 bpm
 Blood pressure - 150/90mmHg 
 Respiratory rate - 36 cpm

Systemic examination:

Respiratory system:
Patient examined in a sitting position.

INSPECTION:-
oral cavity- Normal
Nose- normal 
Pharynx-normal 
Respiratory movements : bilaterally symmetrical 

Trachea - central in position .
Nipples are in the 4th Intercoastal space(ICS)

Apex impulse visible in 5th intercostal space

PALPATION:-
All inspiratory findings are confirmed
Trachea - central in position
Apical impulse @ left 5th Intercoastal space.
Respiratory movements - Bilaterally(B/L) symmetrical .
Tactile and vocal fremitus - reduced on both sides in infra axillary and infra scapular region.

PERCUSSION- 
Dull in both sides

AUSCULTATION- 
Decreased on both sides.
bronchial sounds - heard .

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 
 Surface of the abdomen - normal 

PALPATION:-
Liver - Not palpable 

PERCUSSION:- Dull note is evident.

AUSCULTATION:- Bowel sounds are heard .

INVESTIGATONS:

USG:




Radiographic findings:




ECG:









PROVISIONAL DIAGNOSIS:

Chronic Kidney Disease on Maintenence Hemodialysis

Management:

INJ. METROGYL @ 100ml/IV/TID
INJ. MONOCEF @ 1gm/IV/BD
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 DRUGS :
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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