52 year old female with shortness of breath

This 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.

This E blog also reflects my patient centered online learning portfolio

CHIEF COMPLAINTS:-
 
A 52 old female has come to the casuality with chief complaints of 
Fever and cough since 1 week
Shortness of breath since 3 days 

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 15 years back and was diagnosed with diabetes  under OHA Tab Glycomen gp1 for 2 years
6 months back patient had an episode of fall 
Patient noticed pedal edema
Shortness of breath
Burning micturition and 
Facial puffiness for 2 days
She was taken to a private hospital and was diagnosed to have increased creatinine levels (7.5)
Patient was under ayurvedic medication for 4-5 months 
Her creatinine levels were 3.5
She stopped ayurvedic medication 20 days back
Since 5 days patient has
   Fever 
  Cough - dry cough
   Burning micturition
   Vomiting
Fever since 2 days with no chills and rigor
No evening rise of temperature
Vomiting 3 days back 2-3 episodes for 2 days
Shortness of breath since 3 days
No aggrevating factors
Patient fell unconscious twice- 19th evening and 20th morning 
Patient also complaints of decreased vision in the left eye 

HISTORY OF PAST ILLNESS

K/c/o of HTN since 15 years 
Medication used - Tab Telma 40mg
K/c/o DM since 20 years
Medication used - Tab Glycomet gp 1

PERSONAL HISTORY:-
 Diet - Mixed
Appetite - Lost since 1 week 
Bowel and bladder movements - Regular 
Sleep - Adequate
No addictions.

FAMILY HISTORY:-

No significant family history 

GENERAL EXAMINATION:-

Patient is conscious, coherent,co-operative 
Well oriented to time and place. 
Pallor - present 
No signs of cyanosis, icterus and lymphadenopathy clubbing

VITALS :-

Temperature - Afebrile 
Bp - 160/90mmhg
Pulse rate - 78/min
Respiratory rate - 22 cycles / min.

SYSTEMIC EXAMINATION

Inspection:
 
 Shape of chest- Elliptical
 Trachea central in position  
 Chest expansion - asymmetrical 
Shoulders drooping no
 kyphosis/scoliosis  no


Palpation:
 All inspectory findings are confirmed with palpation.
  Tactile Vocal Fremitus - Felt 

                                    R.                L
Supraclavicular         R.                R
Infraclavicular.          R.                 R
Mammary.                 R.                 R
Axillary.                      R.                 R
Infra axillary.              R.                 R
Suprascapular.           R.                 R
Interscapular.              R.                R
Infrascapular              R.                 R
  
   

Percussion

                                 Right         Left
Supraclavicular        R.               R
Infraclavicular.         R.               R
Mammary.                 R                R
Axillary.                     R.                R
Infra axillary.              R                R
Suprascapular.          R.              R
Interscapular.             R                R
Infrascapular              R              R


Auscultation:
 
Crepts heard in all areas

  
Cardiovascular Examination:
Thrills: no
Cardiac sounds: S1, S2 heard
Apexbeat in 6th intercostal space mid clavicular line.
Cardiac murmurs: No

CNS:- 
Memory intact 
Higher mental functions normal

ABDOMEN:-

Inspection:
Shape of abdomen :obese 
Umbilicus : central and inverted 
No scars are visible.
Tenderness :no
Palpable masses: no
No organomegaly.
No sinuses

Palpation:
No palpable liver
No palpable spleen
Bowel movements : regular




INVESTIGATIONS
 AKI on CKD with Left ventricular heart failure and pulmonary edema
DM 
HTN

TREATMENT

Inj Lasix 40mg BD
Tab Nodusis 500mg BD
Tab Dolo 650 mg SOS
Inj Neomol 18m IV SOS
Tab Telma 20mg OD 
Tab Nicardia 10mg OD 
Syrup Ascoril D 10ml TID


 



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