48 F SOB 7 days & Pedal oedema 5 days
Patient was apparently asymptomatic 1 week ago then she developed shortness of breath which was sudden onset Grade 3 and progressed to Grade 4 ( NYHA CLASS 4 )
Patient also complaining of pedal oedema B/L pitting type , which is extending upto ankle. Grade 3
Patient also complaining of cough ,insidous onset non productive , not associated with sputum , no diurnal variation .
H/o Orthopnea
No H/o PND
N/o H/o Chest pain , palpitations
History of past illness
4 years ago
Patient had admitted with the similar complaints of pedal oedema & noticed deranged renal parameters & diagnosed CKD for which they treated symptomatically with medications
2 years ago
Pedal oedema & treated symtomatically with medications
3 months ago
Similar complaints pedal oedema & sob for which patient adviced to undergo dialysis .
K/c/o HTN since 9 years and on medication
Tab . Amlodipine 5mg OD
Not k/c/o DM,Thyroid disorders ,BA ,CVA,CAD, Epilepsy ,TB.
PERSONAL HISTORY:
Diet – Mixed
Appetite – Normal
Sleep – Decreased
Bladder & Bowel movements – Regular
GENERAL PHYSICAL EXAMINATION
Patient was concious coherent cooperative
Well oriented to time place person
Moderately build and nourished
Pallor present
No Icterus
Pedal oedema present
No cyanosis
No clubbing
No koilonychia
No lymphadenopathy
JVP - Raised
VITALS
Temperature – Afebrile ( 98.6 F )
Pulse rate – 85 bpm , regular
Respiratory rate – 26 cpm
BP – 180/100 mm Hg
SPO2 – 98% on room air
GRBS – 176 mg/dl
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
INSPECTION
Chest is elliptical , bilaterally symmetrical.
Trachea appears to be central
Movements are equal bilaterally
JVP:Raised
Visible epigastric pulsations
No scars or sinuses
Apical impulse seen in 6th intercostal space lateral to midclavicular line
PALPATION
All the inspectory findings are confirmed
Trachea is central
Apical impulse felt at 5th intercostal space lateral to midclavicular line.
AUSCULTATION
S1 S2 heard no murmurs
RESPIRATORY SYSTEM
INSPECTION
Chest is elliptical shaped,
bilateral symmetrical.
Trachea is central
Movements are equal bilaterally
No scars or sinuses
Apical impulse is not seen
PALPATION
All inspectory findings are confirmed: Trachea is central, movements equal bilaterally.
Antero-posterior diameter of chest >Transverse diameter of chest
Apex beat felt in 6th intercostal space lateral to midclavicular line
PERCUSSION
Resonant note heard in all areas bilaterally
AUSCULTATION
Bilateral air entry present – Normal vesicular breath sounds heard
PER ABDOMEN
INSPECTION
Shape of abdomen appears to normal
No Visible epigastric palpations
No engorged veins sinus scars
PALPATION
All inspectory findings conformed
Abdomen soft & Non tender
No organomegaly
PERCUSSION
Tympanic note heard all quadrants abdomen
AUSCULTATION
Bowel sounds heard
CENTRAL NERVOUS SYSTEM
HMF - Intact
Speech – Normal
No Signs of Meningeal irritation
Motor and sensory system – Normal
Reflexes – Normal
Cranial Nerves – Intact
Gait – Normal
Cerebellum – Normal
GCS Score – 15/15
Clinical pictures
Investigations
At the time of admission
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