A 40yr female came with the complaints of SOB since 1 day

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. 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 

A 40yr old female came with the complaints of SOB since 1 day 

HOPI 

Patient was apparently asymptomatic 6months back and then developed b/l pedal edema and took medications 

2 months back symptoms increased and sob and went to nlg admitted for 3 days for sob grade 4 

C/o nausea and vomiting since 2 months- continuous, water in consistency, non bilious , non projectile 

C/o Facial swelling and peri orbital swelling started 2 months back and nlg Dr's advised dialysis and patient went to Gandhi hospital and got admitted but dialysis sessions delayed so they went to NIMS hsptl and got admitted for 2 days and dialysis 1 session done and got discharged

And then after 3 days symptoms started again and went to NIMS again and Dr adviced for dialysis sessions twice /month 5 sessions of dialysis done 

And discharged and came to our hospital. 

C/o SOB -Grade 4

C/o vomitings- continuous , watery in consistency,non bilious,non projectile since 2months 

Past history: 

K/c/o HTN 5 yrs and on telma 40mg

K/c/o DM 12yrs and on Glimiperide 1mg+ metformin 500mg 

Personal history: 

Diet mixed 

Appetite decreased since 1month 

Sleep Adequate

Bowel and bladder regular 

No addictions 

General examination

Pat is c/c/c well oriented to time place person 

Moderately built and nourished 

Pallor present 

B/L Pedal edema present  

Facial swelling present 

No signs of icterus cyanosis clubbing lymphadenopathy generalized edema 

 

 

 

 

 

 

 

Vitals : 

Temperature 97.6 

PR 112

 BP 180/90 

Spo2 96 at ra 

Grbs 213 mg/dl 

Systemic examination

CVS S1 S2 Heard no murmurs

RS BAE Present NVBS heard 

Per abd : 

Inspection-

Shape of the abdomen:Distended 

Flanks:Free 

Umbilicus:center,oval shape 

Skin-dry scaly ,no sinuses,scars,striae 

No dilated viens 

Abdominal wall moves with respiration 

No hernial orifices 

Palpation:

No local rise of temperature,no tenderness.All inspectory findings are confirmed by palpation. 

Liver:Not palpable,Non tender,no hepatomegaly

Spleen:Not palpable,non tender,no splenomegaly 

Kidney:Non tender and not palpable 

No other palpable swellings

CNS : NFND 

Provisional diagnosis: 

CKD ON MHD with K/C/O HTN AND DM -TYPE 2 with ANAEMIA 

Investigations: 

Treatment: 

TAB.NICARDIA 10MG PO/TID

TAB.ARKAMINE 0.1MG PO/OD 

INJ.HAI SC TID  

TAB.NODOSIS 500MG PO/BD 

TAB.SHELCAL 500MG PO/OD 

TAB.OROFER XT PO/OD 

TAB.DOLO 650MG PO/SOS