Long case - Final MBBS Practical examination

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A 30 year old female patient, who is a housewife and resident of Nalogonda came to OPD with chief complaints of :

Puffiness in face and pedal edema since - 2 days.
Shortness of Breath since  - 2 days.
Abdominal pain since - 2 days.

History of presenting illness :

Patient was apparently asymptomatic 7 months ago.Later on  she developed facial puffiness and B/L leg swelling which was pitting in nature.
SOB: Insidious in onset , which then gradually progressed to grade 4 , not affect with change in position,  no aggravating and relieving factors .
Abdominal pain : epigastric pain 
since 7 days which started suddenly and Burning type of pain .
Past history 
She is a known case of hypertension since 12 years .

Personal history :
Diet - mixed 
Appetite - Decreased
Sleep  - Inadequate 
Bladder - Decreased urine output
Bowel movements - normal 
No addictions.
 
Family history:
Patient mother is a hypertensive .

General examination:

Pallor - present 
Icterus -  absent 
Cyanosis - absent 
Clubbing - absent 
Lymphadenopathy - absent 
Edema - absent 
Edema : absent











Vitals:
 Temperature - Afebrile
 Pulse - 110 bpm
 Blood pressure -  150/90mmHg 
 Respiratory rate - 36 cpm

# Systemic examination:

Respiratory system:

Patient examined in a sitting position.

INSPECTION:-
oral cavity- Normal
Nose- normal 
Pharynx-normal 
Respiratory movements : bilaterally symmetrical 

Trachea - central in position .
Nipples are in the  4th Intercoastal space(ICS)

Apex impulse visible in 5th intercostal space

PALPATION:-
All inspiratory findings are confirmed
Trachea - central in position
Apical impulse @  left 5th Intercoastal space.
Respiratory movements - Bilaterally(B/L) symmetrical .
Tactile and vocal fremitus - reduced on both sides  in infra axillary and infra scapular region.

PERCUSSION- Dull in both sides

AUSCULTATION -  Decreased on both sides.
bronchial sounds - heard .

Cardiovascular system 
JVP -raised
Visible pulsations-  Absent 
Apical impulse - shifted downward and laterally 
Thrills -absent 
S1, S2 - heart sounds muffled 
Pericardial rub -present 

Abdomen examination:

INSPECTION :
Shape  - Distended 
Umbilicus - normal 
Movements - normal
Visible pulsations - absent 
 Surface of the abdomen - normal 

PALPATION :
Liver - Not palpable 

PERCUSSION - Dull note is evident.

AUSCULTATION - Bowel sounds are heard .

INVESTIGATONS

USG:



Radiographic findings:

ECG:















PROVISIONAL DIAGNOSIS:

 CKD on MHD

Management :

INJ. METROGYL  @ 100ml/IV/TID
INJ. MONOCEF @  1gm/IV/BD
INJ PAN  40mg/IV/OD
INJ. ZOFER.  4mg/iv/SOS
TAB. LASIX.  40mg/PO/BD
TAB. NICORANDIL  20mg/PO/TID
INJ. BUSOCOPAN  /IV/stat 

Add on DRUGS :
TAB. OROFENPO@ BD
TAB. NODOSIS 500mg/PO/TID
INJ.EPO  4000 ml/ weekly 
TAB. SHELLCAL/PO/BD 
DIALYSIS (HD)
INJ.KCL 2AMP IN 500 ml NS over 5min.

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