1601006039 SHORT CASE

 

short case 1601006039

 SHORT CASE :

This is an online e logbook to discuss our patients deidentified health data shared after taking her/guardian's signed informed consent.
Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.
This E log also reflects my patient centre’s online learning portfolio and valuable inputs on the comment box is welcome."

A 45 yr old male patient who is a farmer by occupation resident of narketpally 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

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.
k/c/o CKD on maintainance Hemodialysis since 10 months
He is not a known case of diabetes mellitus ,  thyroid, epilepsy , Asthma , TB

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


👉 elevated JVP




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.
chest X RAY : 
    Cardiomegaly is seen
ECG : SINUS TACHYCARDIA. 

provisional diagnosis:

HEART FAILURE SECONDARY TO CKD.

Comments

Post a Comment

Popular posts from this blog

  2K16 BATCH UNIVERSITY PRACTICAL EXAMS    DEPARTMENT OF GENERAL MEDICINE   DATE: 26.04.2021 (MONDAY) S. NO HALLTICKET NO CASE BLOG LINKS  CASE PRESENTATION VIDEO LINKS      1 1601006001 LONG CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006001-long-case-april-23-2021-hall.html SHORT CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006001-short-case-april-25-2021.html https://youtu.be/9xE26ZkzqDg 2 1601006002 LONG CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006002-long-case.html SHORT CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006002-short-case.html https://youtu.be/7jBj-Fz8kc4 3 1601006003 LONG CASE https://mbbs2k16batchgmpracticals.blogsp...
Read more

1601006161 SHORT CASE

Image
  SHORT CASE : A 34-YEAR-OLD GENTLEMAN WITH CHRONIC KIDNEY DISEASE UNDERGOING DIALYSIS   HALL TICKET NUMBER : 1601006161 A 34-year-old gentleman, from Motukur, who is a labourer by occupation, came to the hospital on 17/04/2021, for Maintenance Hemodialysis. History of presenting illness : The patient was apparently asymptomatic 3 years ago, when he was diagnosed with  Hypertension, secondary to Chronic Kidney Disease.  He was regularly taking his medication for Hypertension, until he  abruptly stopped  doing so 2 months ago. The patient has been  undergoing maintenance hemodialysis at our hospital since the past 10 months . He complains of facial puffiness, abdominal distension and swelling in the legs.  The patient also complains of loss of weight over the past 3 years. Initially, he was 63 kg, now he is 52 kg. General Physical Examination : The patient is conscious, coherent and cooperative, lying supine on the bed He is well oriented to time, ...
Read more

1601006107 LONG CASE

Image
  LONG CASE : A 50-YEAR-OLD LADY WITH LEFT-SIDED WEAKNESS OF THE BODY AND DEVIATION OF THE MOUTH TOWARDS THE RIGHT A 50-year-old lady, from Suryapet, who is a homemaker, came to the hospital on 20/04/2021 at 3 PM, and was examined on 24/04/2021 at 10 AM, with Chief Complaint s  of : 1) W eakness of the left upper and lower limbs since 5 days 2) Deviation of the angle of mouth towards the right since 5 days 3) Slurred speech since 5 days. History of Presenting illness  :  The patient was apparently asymptomatic  5 days ago , when  at around 9 AM in the morning, on 20/04/2021 : She felt a sudden  weakness of her left upper and lower limbs. The episode was  sudden in onset, initially began as a slight weakness of the left upper limb, which progressively worsened with time and the evolution of weakness had completed within 6 hours ,  with a complete inability to move both - her left upper and lower limbs ,   following which she was brought t...
Read more