A 45 year old female with SOB
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Case Report:
A 45 year old female with daily wage labourer by occupation came to opd with chief complaints of:
Generalised body swelling: 2months
Facial puffiness:2months
Shortness of breath:2 hrs
HOPI:
Patient was apparently asymptomatic 6 yrs back one fine day she had giddiness for which she went to a local hospital where she was diagnosed with diabetes and was using OHA since then
1 year later she again felt dizzy & was diagnosed with HTN - on treatment since then
Since last 1 year she started to have pedal edema on & off + bilateral knee pains bcz of which she is not able to do work as usual
4 months back she developed pedal edema, facial puffiness progressed to anasarca, loss of appetite & generalized weakness for which she went to a local hospital in nalgonda where she was diagnosed with renal failure and was given some medication
Fever 2months ago-low grade, intermittent and no diurnal variation
She felt symptomatically better until 10 days back when she again developed anasarca, low back ache & generalized body pains for which she visited our hospital and hemodialysis was advised
But patient refused and went home due to personal problems
10 days later on 23-04-2023 afternoon hours she was again brought to our hospital with chief complaints of sudden onset SOB since morning
SOB grade-4 associated with orthopnea
No history of chest pain, palpitation, or syncope
No history of fever, cold, or cough
No history of decreased urine output or dysuria
PAST HISTORY:
Patient is k/c/o DM since 6 years and was on OHA (T.GLIMIPERIDE 1mg + METFORMIN 500mg OD)
K/c/o HTN since 5 years and was on treatment (T.ATENOLOL 50mg OD)
No h/o CAD, CVA, Asthma, TB, or Epilepsy
FAMILY HISTORY:
hypertension and diabetes-Mother
PERSONAL HISTORY:
Wakes at 6am,goes to work at 9 am & works in the field for 7 to 8 hrs,returns home at 6-7 pm, goes to sleep at 10pm
Mixed diet & decreased appetite
Sleep adequate
No bowel and bladder disturbances
No addictions
GENERAL EXAMINATION :
Patient was conscious, coherent & cooperative
Oriented to time, place & person
Heavily built & nourished
Pallor -present
Pedal edema- present b/l pitting type extending upto shin of tibia
No icterus, cyanosis, clubbing, koilonychia, lymphadenopathy
VITALS:
Pulse rate -92 beats/min
BP- 190/110 mmHg in both arms
RR- 28 cpm
SpO2- 78% on RA - 92% on 12 lit O2
GRBS- 168 mg/dl
SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM:
Inspection:
Chest is bilaterally symmetrical
No precordial bulge
Apex impulse visible in 6th intercostal space at midclavicular line
No visible pulsations, sinus, scars, or dilated veins.
Palpation:
All inspection findings are confirmed
Apex impulse - felt in 6th intercostal space at midclavicular line
No parasternal heave
No palpable thrills
Auscultation:
Mitral area - S1 and S2 heard, no murmurs
Aortic area - S1 and S2 heard ,no murmurs
Pulmonary area - S1 and S2 heard ,no murmurs
Tricuspid area - S1 and S2 heard ,no murmurs
RESPIRATORY SYSTEM:
Inspection:
Chest is elliptical & bilaterally symmetrical
Trachea appears to be central
Movements appear to be equal on both sides
No visible pulsations, sinus, scars, or dilated veins.
Palpation:
All inspection findings are confirmed
Trachea central
Movements equal on both sides
Transverse diameter > Antero-posterior diameter
Apex beat felt in 6th intercostal space at midclavicular line
Tactile vocal fremitus: equal on both sides in all areas
Percussion:
Resonant note heard in all areas
Auscultation:
Bilateral air entry present
Normal vesicular breath sounds were heard
Fine crepts heard bilaterally in mammary, infra mammary, axillary, infra axillary & infra scapular areas
Right Left
Supraclavicular NVBS NVBS
Infraclavicular NVBS NVBS
Mammary Fine Crepitations
Inframammary Fine Crepitations
Axillary Fine Crepitations
Infraaxillary Fine Crepitations heard
Suprascapular NVBS NVBS
Infrascapular Fine Crepitations heard
PER ABDOMEN:
Obese abdomen
Midline inverted umbilicus
LSCS scar + over lower abdomen
No visible pulsations/engorged veins/sinuses
Soft, non-tender, no organomegaly, no free fluid
Bowel sounds present
CENTRAL NERVOUS SYSTEM:
HMF - Intact
R. L.
MOTOR SYSTEM: Power: UL 4/5 4/5
LL 4/5 4/5
TONE - Normal.
REFLEXES - B. T. S. K. A. P.
R. +2 +2. +1. +2. --. Flexion.
L. +2. +2. +2. +2. --. Flexion.
CRANIAL NERVES - Normal.
Provisional diagnosis:
This is a known case involving renal system probably chronic kidney disease since 4months
Type 2 diabetes since 6years and hypertension since 5years
There is severe anemia secondary to chronic kidney disease.
left heart failure(symptoms suggestive Shortness of breath associated with orthopnea)
Investigations:
25/4/2023
SOB decreased
Edema decreased
Appetite improved
No other complaints
Patient is c/c/c
Temp:- 98.4° F
PR- 78 bpm
RR- 20 cpm
BP- 160/90mmHg
Spo2- 95% at room Air
GRBS- 135 mg/dl
Input- 500 ml
Output- 300ml
CVS- s1s2 present, no murmurs heard
RS- B/L air entry present, NVBS heard
Fine crepts in b/l infra axillary & infra scapular areas
PA- soft, NT
CNS- NFND
Hemodialysis
Diuresis & other supportive care
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