53 year old female came to OPD with chief complaints of difficulty in breathing and cough

A 53 year old female with chief complaints of difficulty in breathing and cough since 4 days

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CASE-

A 53 year old female patient came to the OPD with chief complaints of

1) difficulty in breathing since 4 days

2) cough since 4 days

History of presenting illness

She was apparently asymptomatic 7months back then she developed fever which is sudden in onset , continuous. It was severe in the night associated with chills and not relieved on medication. 

She developed pedal edema 7months back which was sudden in onset, relieved on walking and aggrevates on sitting .

She had an episode of vomiting early in the morning everyday, about 20ml yelllow color bilious.

She  also developed shortness of breath 4 days back which was grade-4 and  sudden in onset gradual in progression no positional variations. Aggravated on exposure to cold environment .

She developed cough 4 days back which was productive,copious amount of expectoration, associated with postural variation more during sleep.

 She has fatigue and tiredness.

 

No history of burning micturation,palpatations,hematuria,

Headache, dizziness, joint pains ,altered sensorium 

Past history: 

She is a known case of hypertension since 15 yrs 

She's using medications from past 10 yrs

She is under hemodialysis once in three days from 7 months . No history of diabetes, asthma , epilepsy, TB

Personal history:

Decreased appetite 

Diet vegetarian

Weight decreased

Sleep disturbance

Oliguria 

Bowel once in three days

No addictions. No allergies 

Family history: 

Insignificant

General examination: 

Patient is examined with informed consent , moderately nourished and moderatly built , patient is conscious coherent and cooperative well orientated to Time place person 

 

Vitals

TEMP- 99.61F

BP-130/90 mmHg

PR- 84BPM

RR-24CPM

pallor is present, 

pedal edema present , 

icterus-absent, 

clubbing - absent , 

cyanosis-absent, 

lymphadenopathy - absent. 

SYSTEMIC EXAMINATION

CVS:-

Thrills- no

Cardiac sounds- S1 S2 present

Cardiac murmurs - no 

RESPIRATORY SYSTEM:-

Dyspnea- no 

Wheeze- no

Position of trachea- central

Breath sounds- vesicular

ABDOMEN:-

Shape of the abdomen- scaphoid

Tenderness - not

Palpable mass - no

Hernial orifice - normal

Free fluid - no 

Bruits - no

Liver not palpable

Spleen not palpable

CNS EXAMINATION:-

Level of consciousness - alert

Speech - normal

Neck stiffness - no

Kernig's - no

Higher mental functions - intact

                                  R                   L     

Power :-  UL          5/5                5/5

                LL           5/5                5/5

Tone :-     UL        normal          normal

                 LL        normal          normal 

       

          B        T         K         A               P

R       Normal

L       Normal

Cerebral signs:-

Finger-nose in-coordination :- no 

Knee-heel in-coordination :- no

INVESTIGATIONS:-

LFT-

RFT-

HEAMOGRAM-

USG-

ECG-

Provisional Diagnosis:-

Chronic kidney failure.

Treatment:-

1)Tab.Nodosis 500mg BD

2)Tab.Lasix 40mg Po/BD 

3)Tab.Bio D3 OD

4)Tab.shelcal 500mg Po/od

5)Tab.Orofex XT po/Bd

6)Tab.Pantop 40mg OD 

7)INJ.Erythropoetin 4000units SC Weekly once

8)INJ.Iron Sucrose 100mg Weekly once in 100ml NS.