54year old female with CKD

 A 54yr old female home maker resident of Nalgonda came to opd with chief complaints of breathless since 10days cough since 10days ,fever since 10days ,swelling in the legs and facial puffiness since 10days and vomiting since 7days 

HOPI 

patient was apparently asymptomatic 10days ago the she developed shortness of breath which was insidious in onset gradually progressive in nature and aggravating on walking and relived on sitting position grade 3 according to mmrc grading 

No h/o orthopneia 

No h/o paraoxysmal nocturnal dyspnea 

Bilateral Pedal edema since 10days which was pitting type seen near the ankles insidious in onset and gradually progressive in nature 

Facial puffiness since 10days started near orbits and gradually progressed to entire face 

 Cough since 10days insidious in onset, gradually progressive ,productive type ,white in color,in small quantity,non foul smelling,non blood stained,with no diurnal variation,with no aggravating and relieving factors

Fever since 10 days insidious onset ,gradually progressive,low grade,intermittent type,associ with chills ,rigors ,body pains with no diurnal variation,relieves temporarily with medication, no aggravating factors 

Vomiting since 7 days non projectile type non blood stained,non foul smelling ,content is food,with 2-3 episodes per day but on Saturday she had 5 episodes of vomiting 

Past history:

K/c/o Asthma since 20 years  -patient is on Salbutamol 

K/c/o hypertension since 10 years-patient is on medication atenolol

-she is having a history of fever 4years ago for which she went to hospital and doctor suspected of having kidney problem and gave sodium bicarbonate.

-No history of diabetes mellitus,tuberculosis,epilepsy

-No history of previous surgeries.

Personal history-

diet -mixed 

Sleep-adequate

Appetite-reduced since 10 days

Bowel and bladder movements-regular

Addictions-none

Family history-no significant family history 

General physical history:

Patient conscious coherent cooperative moderately built and nourished

No pallor,icterus, cyanosis,clubbing,lymphadenopathy,edema

Temperature :

Pulse Rate: 80 beats per minute 

Respiratory rate: 18 times per minute 

BP: 

SpO2 : 87% at room temperature

GRBS- 95 mg / dl

Systemic examination 

Respiratory 

On inspection

Nose

No structural abnormalities found in nose 

No obstruction in nose and nasal polyps are seen 

Oral cavity 

No oral lesions 

No crooked teeth 

Trachea

Appears to be central 

Chest 

Bilateral symmetrical 

Elliptical in shape 

Chest expansion is equal on both sides 

No engorged veins are seen 

PALPATION 

No local rise in temperature and no tenderness 

The position of trachea is confirmed by 3finger test 

Apical impulse present 

Chest expansion is equal on both sides 

Anterior posterior diameter-17cm

Transverse diameters-28cm 

Vocal fremitus 

 They are equal on both sides 

Percussion                         Right                 Left 

Supraclavicular	Resonant	Resonant
Infraclavicular	Resonant	Resonant
Axillary	Resonant	Resonant
Infraaxillary	Resonant	Resonant
Suprascapular	Resonant	Resonant
Infra scapular	Resonant	Resonant
Interscapular	Resonant	Resonant
Mammary	Resonant	Resonant

Auscultation 

Right

Left

Supraclavicular	Nvbs	Nvbs
Infraclavicular	Nvbs	Nvbs
Axillary	Nvbs	Nvbs
Infraaxillary	Nvbs	Nvbs
Suprascapular	Nvbs	Nvbs
Infrascapular	Nvbs	Nvbs
Interscapular	Nvbs	Nvbs
Mammary	Nvbs	Nvbs

Per abdomen examination: 

On inspection

Shape of abdomen : scaphoid

Umbilicus : inverted 

Movements of abdomen wall with respiration 

No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites 

On palpation 

No local rise of temperature 

Inspectory findings are confirmed 

Soft and non tender

No palpable mass 

Liver and spleen not palpable 

On percussion 

Tympanic note heard

On auscultation 

Bowel sounds heard 

CVS examination:

S1 S2 heard 

No murmurs heard 

CNS examination :

No focal neurological deficits 

Investigations