LONG CASE - A 22 year old female came to the OPD with chief complaints of generalised swelling over the body and decreased urine output and

 LONG CASE: FINAL PRACTICAL

MEDICAL CASE

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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 i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

Viharika Vupputuri

June 15 , 2022

Hall ticket no- 1701006197

CASE DISCUSSION

A 22year old female came to the OPD with the chief complaints of 

 Generalised swelling over the body since 6   days.

  Decreased urine output since 6 days.

   Shortness of breath since 5 days

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 6 days back and then she developed generalised swelling of the body and reduced urine output and shortness of breath.

No H/o cold, cough,fever, chest pain , orthopnea , palpitations.

PAST HISTORY

Known case of diabetes mellitus since 15 years on insulin.

Hypertension since 2years on Tab. Telma

 40mg and Tab. Nicardia 20mg.

Not a known case of asthma , tuberculosis and epilepsy.

PERSONAL HISTORY

Diet - Mixed 

Appetite - decreased

Bowel and bladder - decreased

No addictions 

No allergies 

FAMILY HISTORY 

Insignificant 

GENERAL EXAMINATION 

Patient is conscious, coherent and cooperative and is moderately built and nourished.

Patient is examined in a well lit room.

Pallor - present

Icterus - absent 

Clubbing - absent 

Cyanosis - absent 

Lymphadenopathy - absent 

Edema - present 

VITALS 

Temperature - afebrile 

BP - 180/100

Pulse rate - 86bpm

Respiratory rate - 24cpm

SYSTEMIC EXAMINATION

CVS 

S1,S2 sounds heard.

No murmurs 

No apex beat 

No palpable heart sounds

RS 

Bilateral Crepitus heard.

CNS 

Cranial nerves - intact 

Motor system - intact 

Superficial reflexes and deep reflexes are present.

No involuntary movements

Sensory system - pain , touch , temperature , vibration well appreciated.

ABDOMEN 

Inspection - 

Shape - distended

Flanks - full

Umbilicus - central position , inverted

No dialated veins, hernial orifice 

No visible pulsations. 

Palpation- 

No local rise of temperature

All inspectory findings are confirmed 

No guarding rigidity.

Deep palpation - no organomegaly 

Percussion - fluid thrill is present 

Auscultation - bowel sounds heard.

PROVISIONAL DIAGNOSIS - 

Chronic kidney disease with maintenance hemodialysis .

INVESTIGATIONS  

Hemogram  

CLINICAL IMAGES

VIDEO ELICITING EDEMA

Ultrasound

Chest X ray

            

                                   ABDOMEN

 TREATMENT 

Inj. LASIX 60mg IV/BD

Insulin infusion 6ml/hr 

Injection PIPTAZ 2.25gm /TID/I

Inj. PAN IV/B

Inj. ZOFER IV/TI

Tab. NICARDIA 20 MG /B

Tab. TELMA 40 MG /O

Tab. OROFER-X5 PO/O

Tab. NODOSIS 500 MG PO/B

Tab. SHELCAL 500MG/PO/OD

Nil by mouth till further orders 

Fluid and salt restriction 

GRBS monitoring regularly.