short case

1601006013

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"

CASE HISTORY 

A 65 year old female from Alingapuram Came to opd 25 days back with complaints of swelling in bilateral lower limbs since 1 week and Shortness of breath since 4 days

The patient was apparently asymptomatic 25 days ago then she developed:

SOB ( shortness of breath )- while sitting and was insidious in onset, gradually progressive ( Grade IV )

Swelling in the legs- started bilaterally in the feet and gradually progressed upto mid calf level ( Grade 2 ) associated with cough.

No h/o chest pain , palpitations, decreased urine output , blood in urine, burning micturition.

General Examination: 

The conscious, coherent, not co operative.

Moderately built, moderately nourished.

Pallor- present 

Edema- pitting type edema

(grade II ) involving both  feet and legs upto mid calf.

Systemic examination:

Respiratory System:

Shape of chest - normal

Inspection of upper respiratory system- 

• oral cavity- normal

• Nose- normal 

• Pharynx- normal 

Lower Respiratory Tract:

Inspection: 

• trachea: central 

• Symmetry of chest  : symmetrical 

• Movement: B/L symmetrical expansion of chest respiration

             

• No scars, engorged veins or sinuses.

Palpation:

All inspectory findings are confirmed by palpation.

• Trachea: central - confirmed by  three finger test.

Assessment of anterior and posterior chest expansion- B/L symmetrical expansion of chest.

No chest wall tenderness 

Vocal fremitus- decreased in inframammary , infra axillary and infra scapular

Percussion :     done in sitting position 

                                       Right            Left

Supraclavicular         Resonant  Resonant

Infraclacicular           Resonant   Resonant 

Mammary                  Resonant   Resonant 

Inframammary         stony dull   stony dull

Axillary                      Resonant   Resonant 

Infraaxillary              stony dull    stony dull 

Supra scapular         Resonant   Resonant 

Interscapular            Resonant  Resonant 

Infrascapular            stony dull  stony dull

Auscultation:

                                     Right            Left

Supraclavicular          NVBS          NVBS

Infraclacicular            NVBS          NVBS

Mammary                   NVBS          NVBS

Inframammary       diminished  diminished

Axillary                       NVBS           NVBS 

Infraaxillary            diminished   diminished

Supra scapular         NVBS            NVBS 

Interscapular            NVBS            NVBS

Infrascapular         diminished   diminished

Vocal resonance - markedly diminished over the fluid area 

Basal crackles are present.

Investigations :

X-Ray 

Renal function Test :

• Raised urea- 94 mg/dl

• Raised creatinine- 6.3 mg/dl

• Raised uric acid - 9.9 mg/dl

Provisional diagnosis:

Renal failure with bilateral pleural effusion