67 year old female with shortness of breath

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CHIEF COMPLAINT

A 67 year old female from nadikuda, farmer by occupation has come to the OPD with chief complaints of shortness of breath, pedal edema and decreased urine output since 3 months

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 1 year back when she noticed decreased urine output and was diagnosed with heart failure and started taking medication for the same.
3 months back she noticed :-
-Bilateral pedal edema -pitting type, extending upto the ankles 

-Shortness of breath - gradually progressing from grade 2 to grade 3 which has subsided now.

-Slight burning during micturition
No history of Cough, cold and fever
Patient visited a local hospital in nalgonda and underwent dialysis twice and one blood transfusion
After which she has come here as the doctor advised 
Patient underwent dialysis thrice here 
1st dialysis - 15/1/23
2nd dialysis - 17/1/23
3rd dialysis - 20/1/23
Patient complaints of left shoulder pain when she is in supine position

HISTORY OF PAST ILLNESS

K/c/o HTN since 30 years 
Medication used -  Tab Arkamine
                                  Tab Nicardia 
K/c/o Diabetes mellitus since 30 years
Medication used - Glimy-3
N/k/c/o Asthma TB Epilepsy

PERSONAL HISTORY

 Diet - Mixed
Appetite - Lost 
Bowel - constipation
Bladder movement - Irregular 
Micturition - slight burning 
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 icterus, cyanosis ,clubbing, lymphadenopathy, pedal edema.

VITALS :-

Temperature - Afebrile 
Bp - 160/100mmhg
Pulse rate - 100/min
Respiratory rate - 16 cycles / min.

SYSTEMIC EXAMINATION:-

RESPIRATORY SYSTEM:-

Inspection:-

Chest is bilaterally symmetrical  
Movements are bilaterally symmetrical.
Position of trachea - central
No Sinuses, Scars, Fistulas

Palpation:-

ALL INSPECTORY FINDINGS ARE CONFIRMED BY PALPATION.

No local rise in temperature
Not tender
Apex beat felt in 5th intercostal space 2cm lateral to midclavicular line .

Percussion:-
Resonant sound is heard

Auscultation: 
Normal vesicular sounds are heard.

CARDIOVASCULAR SYSTEM:-

Inspection:-
Bilaterally symmetrical chest
No visible engorged veins,scars or sinuses on chest.

Palpation:-
S1 S2 are heard
No thrills , no murmurs 
Apex beat present at 5th intercostal space 2cm lateral to midclavicular line .

Auscultation:-
Cardiac rate - 100 beats per minute 
No cardiac murmurs heard.
 
ABDOMEN:-

Inspection:-
Shape of the abdomen - Distended
Flanks- full
Umbilicus - central and inverted 
Sinuses and scars - not visible
No dilated veins

Palpation:-
No local rise in temperature
No tenderness
No palpable mass
No organomegaly
Hernial orifice -normal
Free fluid - yes
No bruits
Liver not palpable
Spleen not palpable

Percussion:-
Shifting dullness - positive

Auscultation:-
Bowel sounds heard

CENTRAL NERVOUS SYSTEM:-

Conscious
Speech is normal
No neck stiffness 
Kernings sign - negative
Memory intact
Cranial nerve normal
Motor sensory nerves normal

PROVISIONAL DIAGNOSIS:-

Chronic renal failure 
Anemia
Resolved heart failure

INVESTIGATIONS


Hemodialysis
Inj frusemide-40 mg/Iv/Tid
Tab:Nicardia-10 mg/Po/Tid
Tab Nodosis 500 mg/Po/Tid 
Inj.pan-50 mg/iv/OD
Tab orofer-Po/OD
Cap BioD3-Po/OD
Inj Erythropoietin-4000iu weekly once
Inj iron sucrose-100 mg/iv in 100 ml NS weekly once

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