Case of a 65 years old female with shortness of breath.
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This is the case of a 65 years old housewife, resident of Nalgonda.
CHIEF COMPLAINT
Patient presented with the chief complaints of
Shortness of breath since 4 days
HISTORY OF PRESENTING ILLNESS
The patient apparently asymptomatic 4 days ago , when in the morning she developed SOB after walking to the bathroom outside her house and coming back ( about 500m)(MMRC Grade 2 SOB) , it was insidious in onset , intermittent , aggravated on walking and eating , and relieved on resting .
No history of orthopnea, PND, fever , cough , chest pain , sweating , palpitations
PAST HISTORY
Not a known case of DM,HTN, Asthma, CVD , Thyroid disorders, Epilepsy
Known case of CKD since 4 years
Hospital admission for acute pancreatitis 4 years ago
FAMILY HISTORY
Not significant
PERSONAL HISTORY
Diet- mixed diet ,
Appetite- normal appetite ,
Regular bowel movements
Normal bladder movements, no burning micturition ,
Addictions-
occasional consumption of alcohol till 4 years ago
Consumption of chutta till 4 years ago
No allergies
EXAMINATION
GENERAL EXAMINATION -
Patient is conscious coherent and cooperative .
Well built and nourished
Oriented to time, place and person.
Pallor , icterus , cyanosis , clubbing , Edema , lymphadenopathy -absent
SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM-
INSPECTIONS
Tachypnic breathing- present
Trachea central
Shape of the chest - elliptical
Chest movements symmetrical
No drooping of the shoulders,
No deformities of chest or spinal cord
No scars and sinuses ,
No chest in drawing
PALPATING
No tracheal deviation
Apical impulse felt
Symmetrical chest movements
No palpable lymph node
Tactile fremitus- normal
PERCUSSION
Resonant tone heard in all areas
AUSCULTATION
Normal vesicular breath sounds in all areas
CVS -
S1, S2 heard
No murmurs
No thrills
Apex beat - normal
No raised JVP
ABDOMEN -
Shape of the abdomen- obese
No organomegaly
Soft , non tender
CNS
No focal neurological defects
PROVISIONAL DIAGNOSIS
?SOB secondary to CKD
INVESTIGATIONS
22/6/23
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