1601006038 LONG CASE

 

Final Practical examination Long case



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Long Case

A 45 yr old male patient who is a farmer by occupation resident of ramannapet came to the OPD with chief complaint of 

Shortness of breath since 1 year and
Pedal edema since 3 months

History of present illness
He was apparently asymptomatic 1 year back then he developed shortness of breath which was insidious onset and gradually progressive from grade 2 to grade 4 it aggravates on lying down and on exertion and relieved on medication.

He also complaints of pedal edema which is insidious onset and gradually progressive starting from ankle to whole of lower limbs.

The patient also complains of decreased urine output since 1 month it is insidious in onset and gradually progressive

There is no history of cough , expectoration, chest pain, no history of palpitations and syncope .No history of fever, sore throat, joint pains. No hemoptysis, hematemesis, no history of Jaundice, no history of burning micturition.

Past history
The patient had a road traffic accident 3 years back for which he underwent surgery on his right leg. The patient was on an analgesic medication for a year
He is a known case of hypertension since 2 years for which he was on medication for year then later discontinued.
He is not a known case of diabetes mellitus ,  thyroid, epilepsy , Asthma , TB

Personal History
Diet-mixed
Appetite-normal
Bladder movement - irregular
Bowel movement - regular
Addictions - he was a chronic alcoholic for 20 years but he stopped since 3 years

Family history
No significant family history

Treatment history
The patient has taken an analgesic for a year
The patient used nicardia 20 mg for a year
He has been on dialysis for 10 months

General examination
The patient is conscious coherent and cooperative Moderately built and Nourished

Pallor is present

There are no signs of icterus , cyanosis , clubbing koilonychia and lymphadenopathy

Bilateral pedal edema is present which is of pitting type


Raised JVP present

Vitals
Afebrile
BP - 130/80mmHg
PR - 82 bpm , regular , normal volume
RR - 24 cpm

Local examination of Cardiovascular system
Inspection
- Trachea appears to be central
- Shape of the chest is normal
- Apical impulse appears to be shifted from normal position
- No visible scars , sinuses 

Palpation
- Trachea is central 
- Apical impulse is shifted about 4-5cm lateral to midclavicular line in the 6th intercostal space



Percussion
- Left heart border is shifted about 4-5cm lateral to mid clavicular line

Auscultation
S1 and S2 is heard
No added murmurs

Per abdomen examination
Inspection

- Abdomen appears to be distended
- Umbilicus is in central position and inverted
- No visible scars or sinuses



Palpation
- There is no local rise in temperature 
- No tenderness 
- No guarding and rigidity 

Percussion
- shifting dullness is present

Auscultation
Bowel sounds are heard

Investigations
Complete blood picture

Hb - decreased
PCV - decreased
RBC count - decreased

CUE
albumin is present in urine

X-RAY
Cardiomegaly is seen

Renal function tests
Urea and creatinine levels are raised

Liver function tests


ECG
Sinus tachycardia
Left axis deviation is seen

Ultrasonography of abdomen

USG -  Grade 2 Renal parenchymal disease

Provisional diagnosis - Chronic Kidney disease with heart failure

Treatment

- Salt and fluid restriction
- Tab. Nicardia 10mg
- Tab. Lasix 40mg 
- Tab. Arkamin 100mcg
- Tab.Orofer XT
- Capsule.  Shelcal


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