Final Practical Examination - LONG Case

Hall Ticket No: 1701006188

Name: Vaishnavi Maguluri 

                                                              LONG CASE

Introduction: This is an online E-log Entry Blog to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs. 

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.

Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references. 

A 70 year old lady, farmer by occupation presented to casualty with the,

CHIEF COMPLAINTS :

1. Shortness of breath since 1 week.

2. Bilateral lower limb swelling since 1 week.

3. Nausea and Vomiting since 3-4 days.

HISTORY OF PRESENTING ILLNESS:

1.  Patient was apparently asymptomatic 6-7 years ago 

2. Patient developed loose stools 1 month back - small quantity, watery consistency, 3-4 episodes per day for 1-2 days associated with pain abdomen. She visited a local hospital, routine investigations done and it relieved with medications given there.

9th MAY

• Hemoglobin: 6.8 g/dl
• Serum Creatinine: 1.8 mg/dl (Normal 0.6-1.2)
• RBS: 205 mg/dl

3. Patient now complains of :-

SHORTNESS OF BREATH SINCE 1 WEEK

- Progressively worsening from initially grade 3 (on exertion and walking short distance) to grade 4 (at rest) presently.

- Associated with cough which is productive, small quantity, whitish color sputum.

🠋

BILATERAL PEDAL EDEMA SINCE 1 WEEK

- Initially till ankle, pitting type now generalized to rest of her body.

- Associated with facial puffiness

- Decreased urine output since 3-4 days

🠋

VOMITINGS SINCE 3-4 DAYS

-Watery in consistency, without any bile stains

• No pain abdomen, no fever.
• No Burning micturition, discoloration of urine.

On 7th June, prior to coming to our hospital, the patient was taken by her son to a local hospital, where following investigations were done:

• Hemoglobin: 5.0 g/dl (Normal 12-14)
• Total RBC Count: 2.15 million/cumm (Normal 4.5-6.5 mill)
• Platelet count: 1.45Lakhs/cumm (N 1.5-4)
• Serum Creatinine: 5.6 mg/dl (Normal 0.6-1.2)
• RBS: 110 mg/dl (Normal 80-170)
• Bilirubin within normal range
• Ultrasound Abdomen normal

DAILY ROUTINE: 

PAST HISTORY:

• Patient is a known case of Diabetes Mellitus type 2, since 6-7 years.
• Patient is not a known case of Hypertension, Thyroid disorders, Seizures, Tuberculosis, Asthma, stroke or any cardiac disorder.
• No history of any previous surgeries.

PERSONAL HISTORY:

• Her appetite has decreased since past 1 week, she consumes a mixed diet, sleep is adequate.
• Bowel movements are normal but Decreased urine output since the last couple of days.
• No history of smoking or alcohol.
• No known food or drug allergies.

FAMILY HISTORY:

• No similar complaints in the family members.

GENERAL PHYSICAL EXAMINATION:

Examination has been done in a well lit room in supine and sitting posture after taking informed consent and after reassuring the patient.

• Patient was conscious, coherent, co-operative and well oriented to time, place and person.
• Moderately built and nourished.
• She is dyspneic despite being on oxygen supplementation and keeps pausing while talking to take breaths.
• She has truncal obesity.
• Pallor present.
• Bilateral pitting edema present upto ankles now generalized with facial and hands puffiness.
• JVP raised.
• No signs of Icterus, Cyanosis, Clubbing, Generalized Lymphadenopathy.

Vitals:

12/06/2022

Temperature - Afebrile

Respiratory Rate - 28 cpm

Pulse Rate - 110 bpm

Blood Pressure - 160/80 mm Hg

SpO2 - 88 at room temp

RBS - 141 mg/dl

13/06/2022

Temperature - Afebrile

Respiratory Rate -  28 cpm

Pulse Rate - 90 bpm

Blood Pressure - 120/80 mm Hg

SYSTEMIC EXAMINATION:

Cardiovascular System :

On Inspection:-

1. Precordium:

• No precordial bulges.
• No engorged veins.
• No scar/sinus.

- Visible pulsations : Pulmonary Artery pulsations.
- No epigastric or any other pulsations.

- Patient is using accessory muscles to breathe.

2. Apex Beat: Appears to be at the 5th Intercostal Space 1cm lateral to midclavicular line.

3. Chest wall Defects: None.

 

On Palpation:-

• Inspectory findings of Apical beat confirmed, can be localized 1cm lateral to the midclavicular line in the 5th Intercostal Space.
• Parasternal Heave : Present, palpated at 2nd intercostal space.

On Percussion:-

cardiac dullness

On Auscultation:-

• S1 ,S2 heard
• Cardiac Wheezing +

Respiratory System: 

• Diffuse crepitations in all the lung areas.
• Bilateral air entry is present. Normal vesicular breath sounds are heard.

Central Nervous System : No abnormality detected.

Per Abdomen : Soft and nontender.

INVESTIGATIONS:

11th JUNE

12th JUNE

- Troponin I increased 69.7 pg/mm (normal 0-11.6)

- Blood urea increased 187 mg/dl (normal 17-50)

- Serum creatinine increased 8.3 mg/dl ( normal 0.6-1.2)

                               

                                       

13th JUNE

- Serum creatinine is 9 mg/dl ( Normal 0.6-1.2 ).

- Electrolytes within normal range: Sodium 136mEq/L, Potassium 3.5mEq/L, Chloride 101mEq/L.

- Blood Urea is 199 mg/dl ( Normal 17-50 ).

- Hemogram:

PROVISIONAL DIAGNOSIS:

Acute Kidney Injury (under evaluation)

- secondary to anemia, heart failure

- secondary to Diabetes

TREATMENT:

1. Inj. LASIX 40 mg /IV/TID

2. IV Fluids NS

3. Inj. HAI SC

4. Inj. PAN 40mg /IV/OD.

5. Inj. ZOFER 4mg /IV

6. Tab. NODOSIS 500mg/BD

7. Tab. OROFER XT PO/BD

8. Tab, SHELCAL 500mg PO/OD

9. Salt and fluid restriction

10. Monitor vitals - BP, RR, PR, SpO2 4 hrly

11. GRBS monitoring 12 hrly