A 45 YR OLD FEMALE WITH SHORTNESS OF BREATH ,PEDAL EDEMA &ABDOMINAL DISTENSION

A 45 YR OLD FEMALE WITH SHORTNESS OF BREATH ,PEDAL EDEMA &ABDOMINAL DISTENSION

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box 


A 45 year old female came to casualty presented with 

CHIEF COMPLAINTS :
Shortness of breath since 3 days
Abdominal distension since 7 days
Pedal edema since 3 days
Tingling and numbness of hand since 2 days
Anuria since 1 day

HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic  days back then she developed  shortness of breath which is insidious in onset aggravated on standing and relieved on lying down.
Her abdominal distension relieved after passing 400ml of urine through foleys Catheterization.


PAST HISTORY:
Patient was daily labourer 15 years back 
H/o Hysterectomy 15 years back
-She worked for 3 years after hysterectomy then she developed lower back pain which relieved on medication given by local doctor. 
-She consulted different hospitals in 10 years and used different medicines to relieve the lower back pain
ON. 16/3 /22 :
PATIENT WAS ADMITTED UNDER ORTHO FOR LOW BACK ACHE &B/L HIP PAIN
&WAS DIAGNOSED WITH OA B/L HIP .
LBA SECONDARY TO ?SPONDYLOARTHROPATHY 

ON 22/3/22 : 
INTRA ARTICULAR INJECTION OF LA WAS GIVEN IN RIGHT
 On 24/3/22:
Ultrasound Abdomen & pelvis done as a part of surgical profile she was diagnosed with CKD (GRADE 3 RPD ) secondary to NSAID Abuse  
-DENOVO DM  since hospital admission
Then patient was referred to General medicine I/V/O CKD (GRADE 3)
- H/O HYPERTENSION SINCE 2 YEARS  and on Tab.CLINIDIPINE 5MG PO/OD 

INVESTIGATIONS:


On 19/3/22

TREATMENT :At Discharge on 28/3/22
1)GRBS ACC TO 7 PROFILE
INJ HAI 6 UNITS ......6 UNITS......6 UNITS
INJ. NPH 4UNITS ......X........... UNITS
2)T. NODOSIS 500 MG PO/TID X 7 DAYS
3)T.ULTRACET 1/2TAB QID X 7 DAYS
4)T. CLINIDIPINE 5 MG PO OD X 7 DAŸS
5)T.LASIX 20MG PO BD X 7 DAYS
6)T.PAN 40MG PO OD X7 DAYS
7)FLUID RESTRICTION <1.5LT / DAY
8)DIABETIC DIET
9)SALT RESTRICTION <2.5gm


 GENERAL EXAMINATION:
Patient is conscious coherent cooperative well oriented to time place and person
No pallor Ictrus, cyanosis, clubbing, lymphoadenopathy

VITALS
TEMPERATURE - 98.5F
PULSE RATE - 102BPM
BLOOD PRESSURE - 100/80MM OF HG 
RESPIRATORY RATE - 
SPO2 -96 % AT ROOM AIR
GRBS-119mg/dl

SYSTEMIC EXAMINATION - 
PER ABDOMEN : SOFT , TENDERNESS OVER UMBILICAL ,HYPOGATSRIC , RT &LT LUMBAR AND INGUINAL QUADRANTS AND 
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BAE +
BILATERAL AIR ENTRY PRESENT
CENTRAL NERVOUS SYSTEM : NAD




PROVISIONAL DIAGNOSIS :
CHRONIC RENAL FAILURE WITH OSTEOPOROSIS WITH B/L SI JOINT DEGENERATION 
INVESTIGATIONS:
Ecg on 5/4/22

USG 

 TREATMENT 5/4/22
1)TAB.NODOSIS 500 MG PO/BD
2)TAB.OROFER XT PO/OD
3)TAB.SHELCAL -CT PO/OD
4)TAB.BIO -D3
5)TAB.HYDRALAZINE 12.5 MG PO/BD
6)INJ.KCL 2AMP IN 100 ML NS IV @4HOURS 
7)TAB.ALDACTONE 25MG PO/OD
8)INJ.PAN 40 MG IV OD
9)INJ.ZOFER 4MG IV BD
10)SYP.POTCHLOR 10ML IN GLASS OF WATER
11)TAB.ULTRACET 1/2 TAB QID

TREATMENT  on 6/4/22
1)TAB.NODOSIS 500 MG PO/BD
2)TAB.OROFER XT PO/OD
3)TAB.SHELCAL -CT PO/OD
4)TAB.BIO -D3
5)TAB.HYDRALAZINE 12.5 MG PO/BD
6)INJ.KCL 2AMP IN 100 ML NS IV @4HOURS 
7)TAB.ALDACTONE 25MG PO/OD
8)INJ.PAN 40 MG IV OD
9)INJ.ZOFER 4MG IV BD
10)SYP.POTCHLOR 10ML IN GLASS OF WATER
11)TAB.ULTRACET 1/2 TAB QID

SOAP NOTES:
AMC
7/4/22,

S:
1.Shortness of breath 
2.Abdominal distension 
3.Pedal edema
4.Tingling and numbness of hand 

O:
Patient is conscious,cohorent and cooperative
Temp:98 F
BP:100/60 mm Hg
PR:82bpm
Spo2:99%

PER ABDOMEN : SOFT , TENDERNESS OVER UMBILICAL ,HYPOGATSRIC , RT &LT LUMBAR AND INGUINAL QUADRANTS
CVS : S1 AND S2 HEARD , NO MURMURS
RS: BAE +
BILATERAL AIR ENTRY PRESENT
CNS: NAD
A:
CHRONIC RENAL FAILURE WITH OSTEOPOROSIS WITH B/L SI JOINT DEGENERATION 
P:
1)TAB.NODOSIS 500 MG PO/BD
2)TAB.OROFER XT PO/OD
3)TAB.SHELCAL -CT PO/OD
4)TAB.BIO -D3
5)TAB.HYDRALAZINE 12.5 MG PO/BD
6)TAB.ALDACTONE 25MG PO/OD
7)INJ.PAN 40 MG IV OD
8)INJ.ZOFER 4MG IV BD
9)SYP.POTCHLOR 10ML IN GLASS OF WATER
10)TAB.ULTRACET 1/2 TAB QID


SOAP NOTES:
AMC
8/4/22,

S:
1.Shortness of breath 
2.Abdominal distension 
3.Pedal edema
4.Tingling and numbness of hand 

O:
Patient is conscious,cohorent and cooperative
Temp:98 F
BP:100/60 mm Hg
PR:84bpm
Spo2:99%

PER ABDOMEN : SOFT , TENDERNESS OVER UMBILICAL ,HYPOGATSRIC , RT &LT LUMBAR AND INGUINAL QUADRANTS
CVS : S1 AND S2 HEARD , NO MURMURS
RS: BAE +
CNS: NAD
Abd girth :94cms
A:
CHRONIC RENAL FAILURE WITH OSTEOPOROSIS OF BILATERAL HIPS WITH B/L SI JOINT DEGENERATION 
P:
1)TAB.NODOSIS 500 MG PO/BD
2)TAB.SHELCAL -CT PO/OD
3)TAB.BIO -D3
4)TAB.HYDRALAZINE 12.5 MG PO/BD
5)TAB.ALDACTONE 25MG PO/OD
6)SYP.POTCHLOR 10ML IN GLASS OF WATER
7)TAB.ULTRACET 1/2 TAB QID


SOAP NOTES:
AMC
9/4/22,

S:
1.Shortness of breath 
2.Abdominal distension 
3.Pedal edema
4.Tingling and numbness of hand 

O:
Patient is conscious,cohorent and cooperative
Temp:98 F
BP:100/60 mm Hg
PR:84bpm
Spo2:99%
Abd.girth:94cms

PER ABDOMEN : SOFT , TENDERNESS OVER UMBILICAL ,HYPOGATSRIC , RT &LT LUMBAR AND INGUINAL QUADRANTS
CVS : S1 AND S2 HEARD , NO MURMURS
RS: BAE +
BILATERAL AIR ENTRY PRESENT
CNS: NAD
A:
CHRONIC RENAL FAILURE WITH OSTEOPOROSIS OF BILATERAL HIPS WITH B/L SI JOINT DEGENERATION 
P:
1)TAB.NODOSIS 500 MG PO/BD
2)TAB.SHELCAL -CT PO/OD
3)TAB.BIO -D3
4)TAB.HYDRALAZINE 12.5 MG PO/BD
5)TAB.ALDACTONE 25MG PO/OD
6)SYP.POTCHLOR 10ML IN GLASS OF WATER
7)TAB.ULTRACET 1/2 TAB QID


SOAP NOTES:
Ward
10/4/22,

S:
1.Shortness of breath 
2.Abdominal distension 
3.Pedal edema
4.Tingling and numbness of hand 

O:
Patient is conscious,cohorent and cooperative
Temp:98 F
BP:100/60 mm Hg
PR:84bpm
Spo2:99%
Abd.girth:94cms

PER ABDOMEN : SOFT , TENDERNESS OVER UMBILICAL ,HYPOGATSRIC , RT &LT LUMBAR AND INGUINAL QUADRANTS
CVS : S1 AND S2 HEARD , NO MURMURS
RS: BAE +
BILATERAL AIR ENTRY PRESENT
CNS: NAD
A:
CHRONIC RENAL FAILURE WITH OSTEOPOROSIS OF BILATERAL HIPS WITH B/L SI JOINT DEGENERATION 
P:
1)TAB.NODOSIS 500 MG PO/BD
2)TAB.SHELCAL -CT PO/OD
3)TAB.BIO -D3
4)TAB.HYDRALAZINE 12.5 MG PO/BD
5)TAB.ALDACTONE 25MG PO/OD
6)SYP.POTCHLOR 10ML IN GLASS OF WATER
7)TAB.ULTRACET 1/2 TAB QID


SOAP NOTES:
AMC
11/4/22,

S:
1.Shortness of breath 
2.Abdominal distension 
3.Pedal edema
4.Tingling and numbness of hand 

O:
Patient is conscious,cohorent and cooperative
Temp:98 F
BP:100/60 mm Hg
PR:84bpm
Spo2:99%
Abd.girth:94cms

PER ABDOMEN : SOFT , TENDERNESS OVER UMBILICAL ,HYPOGATSRIC , RT &LT LUMBAR AND INGUINAL QUADRANTS
CVS : S1 AND S2 HEARD , NO MURMURS
RS: BAE +
BILATERAL AIR ENTRY PRESENT
CNS: NAD
A:
CHRONIC RENAL FAILURE WITH OSTEOPOROSIS OF BILATERAL HIPS WITH B/L SI JOINT DEGENERATION 
P:
1)TAB.NODOSIS 500 MG PO/BD
2)TAB.SHELCAL -CT PO/OD
3)TAB.BIO -D3
4)TAB.HYDRALAZINE 12.5 MG PO/BD
5)TAB.ALDACTONE 25MG PO/OD
6)SYP.POTCHLOR 10ML IN GLASS OF WATER
7)TAB.ULTRACET 1/2 TAB QID
8)plan for discharge

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