General medicine final practical long case
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.
M.sri sai pavan
Hall ticket no : 1701006105
CASE SCENARIO;
A 22 year old female daily wage worker by occupation resident of miryalaguda came to OPD with the chief complaints of
# Generalized edema since 6 days
#decreased urine output since 6 days
HOPI:
she was apparently asymptomatic 6 days back then she developed generalised edema ,which is insidious in onset, initially started in the face and then extended to involve whole of the body .oedema is of pitting type ,no aggravating and relieving factors.
Decreased urine output since 6 days.
No h/o burning micturition
No h/o hematuria
No h/o cough and fever
No h/o abdominal pain
No h/o chronic cough and weight loss
No h/o headache and blurring of vision
PAST HISTORY;
H/o similar complaints 15 days back
K/c/o DM TYPE 1 SINCE 12 YEARS and on medication (isophane insulin)
K/C/O HTN since 1 year on medication Telma 40 mg and nicardipine 20 mg
NO H/O TB,ASTHMA,CAD, EPILEPSY
PERSONAL HISTORY;
DIET:MIXED DIET
APPETITE: DECREASED
BOWEL AND BLADDER: BOWEL IS REGULAR BUT THERE IS DECREASED URINE OUTPUT SINCE 6 DAYS
SLEEP -ADEQUATE
FAMILY HISTORY;
NO H/O DM,HTN,TB, ASTHMA IN the family
GENERAL EXAMINATION;
AFTER TAKING CONSENT and after adequate exposure,she is examined in a well lit room .
She is conscious, coherent and cooperative
She is oriented to time ,place and person.
On examination there is pallor.
No icterus, clubbing, cyanosis lymphadenopathy.
Generalised edema is present(pitting type)
VITALS:
TEMPERATURE - FEBRILE(99.5)
PULSE RATE-90 BPM
RR-23 CPM
BP-140/90mmhg measured in supine position in left upper arm
Spo2- 96%at room air
Grbs; 203mg/dl
SYSTEMIC EXAMINATION;
PER ABDOMEN;
INSPECTION;
shape of ABDOMEN ; round and distended
Umbilicus - inverted and central in position
No visible scars and sinuses
No engorged veins
PALPATION;
Inspectory findings are confirmed
Soft and non tender
No organomegaly
Fluid thrill is present
AUSCULTATION;
Normal bowel sounds heard
No bruit heard
RS :
On inspection B/L SYMMETRICAL CHEST
on palpation,decreased movement of chest on both lower lobes(infrascapular and infra axillary areas)
On percussion there is Stony dullness over both lower lobes
On AUSCULTATION,there is absent breath sounds over both lower lobes
CNS; intact , NAD
CVS; S1,S2 heard ,no murmurs
PROVISIONAL DIAGNOSIS
Chronic kidney disease on MAINTENANCE HEMODIALYSIS
INVESTIGATIONS;
CBP;
Hb-6.5g%
RBC COUNT:2.42million/cumm
TC -7100cells/cumm
PCV:19.4%
MCV:80.2fl
MCH:26.9
RDW-SD:41.9
Blood urea;110 mg/dl ;on 10/06/22 and on 11/06/22 -127mg/dl
Serum creatinine; 6.2 mg/dl
Serum electrolytes;
Na-136 mEq/l
K-3.5mEq/l
Cl-97 mEq/l
SEROLOGY;
HbsAg-negative
Anti Hcv antibodies -non reactive
HIV 1/2 rapid test -non reactive
USG;
IMPRESSION;
B/L grade 2 Renal parenchymal disease
GROSS ASCITES
B/L MODERATE TO GROSS PLEURAL EFFUSION
Chest XRay;
TREATMENT;on 10/06/22
INJ.LASIX 60 mg/iv/BD
Inj.Human act rapid insulin 6U/iv /stat
Insulin infusion 6ml/hr (1 ml of insulin in 39 ml NS)
Tab.nicardia 20 mg / po/oD
Tab.telma 40 mg /PO/OD
NBM till further orders
Fluid and salt restriction
Grbs monitoring hourly
Treatment on 11/06/22
Inj.LASIX 60 mg /iv/BD
Insulin infusion 6ml /hr (1 ml of insulin in 39 ml NS)
Tab.nicardia 20 mg /po/BD
Tab.TELMA 40 mg /po/oD
NBM till further orders
Fluid and salt restriction
Grbs monitoring hourly
Hemodialysis done 10 days back .5 times .
