A 43 yr old female came with the complaints of SOB since 3 days

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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 43 year old female came with the chief complaints of and shortness of breathe and decreased urine out since 3 days 

HOPI: Patient was apparently asymptomatic 1 year back and then 

 -she had  stomach pain which was dull aching  sudden in onset progressive no aggravating factors and relieved on rest 

 -had 4 episodes of vomitings which was non bilious, food as content non projectile  and went to near by hospital and took medications still the symptoms didn't subside and continued the treatment(not known by the attender) 

Then went to nalgonda and got treated symptomatically 

-4months back patient felt unconscious at home and they took her to NIMS hospital where investigations were done and her blood creatinine levels were around 12 mg/dl and underwent 4 dialysis sessions and stopped after her  creatinine levels were normal  

-At NIMS chest x ray was done and said there was lung infection and was discharged 

-on 04/10/2023,came to KIMS OPD and her creatinine levels were around 8mg/dl and advised dialysis 

-After that she had ORTHOPNEA and ANURIA since 3 days 

PAST HISTORY: 

H/O CKD 1Yr back 

K/C/O HTN Since 1yr and on medication: 

TAB.CINOD 10MG PO/OD 

TAB.CARVEDILOL 6.25MG PO/BD 

K/C/O Hypothyroidism since 2 weeks and on medication:

TAB.THYRONORM 25MCG PO/OD 

H/O TB 10yrs back and took medications for 1 yr 

N/KC/O DM, Epilepsy, CAD, CVA 

PERSONAL HISTORY: 

Diet:Mixed 

Appetite:Normal 

Bowel movements: Regular 

Bladder movements: Decreased urine output 

No known allergies 

No addictions

GENERAL EXAMINATION: 

Patient was c/c/c and well oriented to time place person 

Pallor present 

No signs of icterus cyanosis clubbing lymphadenopathy generalized edema 

Vitals: 

Temperature -98.4F 

PR- 84/min 

RR- 24 cpm 

BP- 140/80mmhg 

Spo2- 98 % at RA 

GRBS- 101Mg/dl 

SYSTEMIC EXAMINATION: 

CVS - S1 S2 Heard, no murmurs 

RESPIRATORY SYSTEM:

-Upper respiratory tract:No DNS,Nasal polyp 

Oral cavity:Good oral hygiene.No loss of tooth/caries.

Lower respiratory tract:

On inspection:

Shape of chest: Elliptical,asymmetric 

Trachea appears to be central

Chest moves on respiration and decreased movements on right side compared to left side

No accessory respiratory muscles are used in respiration.

Apical impulse is not visible.

No scars, sinuses,engorged veins.

No kyphosis, scoliosis.

Palpation:

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

Trachea-central position 

Apex beat-5th ICS medial to midclavicular line 

Tactile vocal fremitus:Decreased in right ICA 

Percussion:on supine position 

Dull note heard over right 2nd and 3rd intercostal spaces 

 Auscultation:Bilateral air entry present.

Crepts heard Left ICA  , Right IAA 

Decreased breathe sounds over Right ICA . 

Added sounds like Rhonchi,wheeze are heard and are diffuse 

Decreased vocal resonance over right ICA 

PER ABDOMEN EXAMINATION:

Inspection:

Shape of the abdomen:Distended

Flanks:Free 

Umbilicus:center,oval shape 

Skin-normal,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 

Percussion: 

On abdomen percussion dull  note is heard

Liver span:12cms in mid clavicular line 

Spleen:No dullness is heard 

CNS : NFND 

Pulmonology referal was done I/v/o Pulmonary kochs 10yrs back and ?h/o aspergillosis with VAP and taken tab.VORNICAZOLE with h/o prolonged intubation 1month back and c/o SOB and advised : 

-Nebulisation with IPRAVENT 6TH hrly 

-inj.LASIX 20MG IV/BD If BP >110/70 mmhg 

USG ABDOMEN DONE : 

-Gross ascites 

-B/L pleural effusion 

Chest x ray done on 4/10/23 

Showing: Right upper lobe fibrosis with mild pleural effusion 

 

PROVISIONAL DIAGNOSIS: 

CKD WITH RIGHT UPPER LOBE FIBROSIS AND MILD  ASCITES  

TREATMENT: 

-FLUID RESTRICTION<1.5l/day 

-SALT RESTRICTION< 2-5 gms/day 

-Tab.CINOD 10MG PO/OD 

-Tab.CARVEDILOL 6.25MG PO/BD 

-Tab.NODOSIS 500MG PO/OD 

-Tab.SHELCAL 500MG PO/OD 

-Tab.OROFER - XT PO/OD 

-Tab. BIO - D3 PO/ WEEKLY ONCE 

-NEBULISATION WITH IPRAVENT 6TH HRLY