Semester 5

Discuss this patient with a view to making a clinical diagnosis.

History
Mdm. JJ is a 67 year old Malay lady with hypertension and diabetes mellitus for 8 years and chronic kidney disease, presented with sudden onset of shortness of breath at rest for 1 day.
There was no chest pain or palpitation. She did not have fever. There was no nausea or vomiting.

Examination
She is a small built woman lying propped up on the bed, alert, and responsive, but restless. She was pale, but had not jaundice, cyanosis, or clubbing. Hydration status was good, evident by good skin turgor and moist tongue. She was on a high flow mask.

Vital signs:
Blood pressure: on admission 200/122mmHg
Pulse rate: 98 beats per minute, regular rhythm, good volume, symmetrical bilaterally
Respiratory rate: 22 breaths per minute.
Temperature: 36.8°C

On examination of the nose, normal septum with pale nasal mucosa was seen and the turbinates were of normal size. No discharge. Her throat was not injected and tonsils were not enlarged. Cervical lymph nodes were not palpable.

Multiple hyperpigmented scars and scratch marks were seen in all four limbs. There was pedal edema on both lower limbs up to knee.

Cardiovascular examination:
There was no precordium abnormality or visible pulsation. Apex beat was deviated to the 6th intercoastal space at the anterior axillary line. There is no parasternal heave or thrills. First and second heart sounds were heard with no murmur or added heart sounds.

Respiratory examination:
The tracheal was central. The chest moved symmetrically on respiration. There is no chest deformity. Chest wall expansion was normal and symmetrical on both sides. Percussion note were resonance and equal bilaterally. Normal vesicular breath sound was heard on both side. There werefine crepitations heard at the bases of both lungs.

Abdominal examination:
The abdomen was convex and moved with respiration. There was no rash, distended vein, visible peristalsis or pulsation. It was soft and non-tender. There was no hepatosplenomegaly. Shifting dullness was negative. Kidneys were not palpable. Bowel sounds were normal.

Central nervous system examination:
Patient was alert, conscious, but irritable. She was orientated to person, time, and place. The cranial nerves were intact. The gait was normal. Test for sensations were not done due to poor cooperation of the patient. Muscle bulk of all four limbs was normal with no involuntary movement, The muscle tone was normal and the power was 5/5 and normal reflexes were elicited on all four limbs.

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