1601006039 SHORT CASE

 

short case 1601006039

 SHORT CASE :

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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.

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