General medicine final practical exam-long case

A 67 year old female with shortness of breadth

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan.


Chief Complaint :-

A 67 years old female came to OPD with chief complaints of
-pedal edema since - 3months.
-Shortness of breath since - 3 months
- Decreased urine output since 3 months. 

•History of present illness:

Patient was apparently asymptomatic 1yr back then she noticed decreased  urine output.She went to a local hospital and was diagnosed as renal failure and heart failure and was on treatment.

Then 3months back she noticed increased Bilateral pedal edema -pitting type, extending till ankles . 
shortness of breath 
Patient visited a local hospital where she has undergone 2 dialysis.
Then 10 days back she visited our hospital where she has undergone 2 dialysis.
Patient complained of pain in back of shoulder due to which sleep is inadequate.
No history of burning micturition, paroxysmal nocturnal dyspnoea,cough, cold, fever.

History of past illness:

K/C/O Hypertension since 30 years, diabetes mellitus since 30 years
Not known case of asthma, tuberculosis, epilepsy.

Personal history :-

 Diet - Mixed
 Appetite - Lost 
 Sleep - inadequate
 bladder movements- Irregular 
 Micturition - Abnormal
 No addictions.

• Family history:- 

No one of family has similar disease.

• General Examination :-

Patient is co-operative coherent consciousness and well oriented to place and time . 
pallor is present
No cyanosis, icterus, lymphadenopathy, clubbing of fingers.
Bilateral pitting edema present

• Vitals : -
 Temperature - Afebrile
 Bp - 160/100 mmHg
 Pulse rate - 100 bpm
Respiratory rate - 16 cycles/ min.

Systemic examination:
  
Respiratory system -

Chest is normal bilaterally symmetrical 
Position of trachea is centralNo scars , sinuses


CVS -

Inspection :

Bilaterally symmetrical chest
No visible engorged veins,scars or sinuses on chest.

Palpation :

Apex beat present at 5th intercostal space 2cm lateral to midclavicular line .

Auscultation : 

S1 S1 heard
No cardiac murmurs heard.

Abdomen - 

Obese, inverted umbilicus. 
No visible scars, sinuses, fistulas, engorged veins.


CNS -

Conscious, speech is normal, no neck stiffness.
Memory intact.

Provisional diagnosis: -
 Chronic renal failure 
 Heart failure
Investigations:

2 D echo
USG abdomen:
For diabetes Tab Glimy 3mg/PO/BD.
For hypertension tab nicardia , Prolomet XL 50
Management:- Hemodialysis

Tab Nodosis 500mg PO/BD
Tab shelcal PO/OD
Tab orofer XT PO/BD
Cap Bio D3 OD
Tab Nicardia 20mg PO/BD
Inj Erythropoietin 4000IU Once weekly











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