A 58 year old female came to opd with SOB

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I have 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 diagnosis and treatment plan. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

CASE DISCUSSION 

A 58 year old Female brought to OPD with chief complaints of

• pedal edema since 10 days

• SOB since 3 days

HOPI

Patient was apparently asymptomatic 10 years back then she developed bilateral pedal edema which was till the ankle and left untreated. 

Later She was diagnosed with hypertension and chronic kidney disease 6 years back on a random health checkup

Then she developed pedal edema 10 days ago initially till ankles now progressed till knees which is of pitting type associated with facial puffiness ; she also complains  of burning micturation , decreased urine output 

3 days ago she developed shortness of breath ( NYHA - grade 4)

PAST HISTORY

K/C/O hypertension - 6 years

K/C/O CKD - 6 years

Patient was diagnosed with chickungunya 15 years back for which she was treated 

pain medication was given to treat the joint and back pain which she kept on using for 10 years

No H/o similar complaints in between

No history of diabetes epilepsy tuberculosis stroke

PERSONAL  HISTORY 

Appetite is normal 

Sleep -normal

Diet - mixed

Bowel moments are regulars

Burning micturation is present 

No addictions

Treatment history 

   Pt is on hypertension medication ( unknown)

     and CKD medication (unknown) for the last 6 years

Family history no significant family history 

 CLINICAL EXAM 

 Patient is conscious coherent cooperative well oriented to time place and person

Moderately built and nourished

PR - 75 bpm

RR - 16 cpm

BP - 120/80mmHg

Temperate- afebrile

Pallor - present 

Icterus - absent 

Cyanosis- absent

Clubbing- absent 

Lymphadenopathy- absent 

Edema - Bilateral pedal edema  

pitting type

ABDOMINAL EXAMINATION

INSPECTION

➤ no distention.

➤Equal symmetrical movements in all the quadrants with respiration.

➤No visible pulsation,peristalsis, dilated veins and localized swellings.

No scars and sinuses are seen

No hernial orifices seen 

PALPATION

no Local rise of temperature  

no tenderness

 ➤ no enlargement of liver

➤No splenomegaly

PERCUSSION-  tympanic sound 

AUSCULTATION

➤ Bowel sounds present.

NO DILATED VEINS

LATERAL VIEW ABDOMEN 

RESPIRATORY SYSTEM- 

Patient examined in sitting position

Inspection:-

Upper respiratory tract - oral cavity, nose & oropharynx appears normal. 

Chest appears Bilaterally symmetrical & elliptical in shape

Respiratory movements appear equal on both sides and it's Abdominothoracic type. 

Trachea central in position & Nipples are in 4th Intercoastal space

No signs of volume loss

No dilated veins, scars, sinuses, visible pulsations. 

Palpation:-

All inspiratory findings confirmed

Trachea central in position

MEASUREMENTS-

AP diameter-                  8 inch

Transverse diameter-    12 inches

AP/T ratio - 0.66

Respiratory movement's:- normal on both sides

Tactile vocal phremitus- increased in  Infraaxillary & infra scapular area. 

Percussion:-

                                       Right                     left

Supraclavicular- Resonant (R)                 (R) 

Infraclavicular-              (R)                        (R) 

Mammary-                     dull                    Dull

Axillary-                          (R)                        (R) 

Infra axillary-                Dull                        Dull

Suprascapular-             (R)                        (R) 

Interscapular-               (R)                        (R) 

Infrascapular-             Dull                         dull

Auscultation:-

                                      Right                     Left

Supraclavicular- Normal vesicular        (NVBS)

                        Breath sounds (NVBS) 

Infraclavicular-          (NVBS)                 (NVBS)

Mammary-                 (NVBS)                 (NVBS)

Axillary-                      (NVBS)                 (NVBS)

Infra axillary-          NVBS                   (NVBS)

                                                          

Suprascapular-          (NVBS)                (NVBS)

Interscapular-            (NVBS)                (NVBS)

Infrascapular-            NVBS                   (NVBS)

CVS EXAM

S1 S2 heard

No murmurs are heard. Apex beat at 6th intercostal space

CNS EXAM

no focal neurological deficits 

Cranial nerves are intact 

INVESTIGATIONS

Haemoglobin - 5.1 gm/ dl

USG FINDINGS BILATERAL PLEURAL EFFUSION 

X -RAY FINDINGS - obscuration costophrenic angles - pleural effusion

Increase in CTR - CARDIOMEGALY 

PROVISIONAL DIAGNOSIS 

1)Chronic kidney disease due to Drug abuse 

2) Chronic heart failure with Cardiomegaly and Bilateral pleural effusion 

3) severe anemia

Treatment 

1. INJ LASIX 40mg IV TID

2.T .NODOSIS 250 mg PO TID

3. T.NICARDIA 10mg PO TID

4.T SHELCAL 500mg PO OD

5.CAP BIOD3 PO OD

6.INJ ERYTHROPOIETIN 4000IU

WEEKLY ONCE IV

7.INJ OROFERS 100mg IN 100ml

NS IV WEEKLY ONCE