1601006050 SHORT CASE

 A 40-year-old gentleman, who is a resident of choutupal, presented to the outpatient department with the :

Chief complaints: 

The patient came with complaints of bilateral swelling of feet since 3 days

History of present illness : 

  • The patient was apparently asymptomatic 3 days ago then he developed swelling in both feet up till the ankle joint, insidious in onset, did not subside with rest as the patient is confined to bed.
  • He also complains of shortness of breath, insidious in onset, gradually progressive present even at rest (grade IV), accompanied by exercise intolerance
  • It was not associated with chest pain, orthopnea, PND, syncope, palpitations, or cough. 

Past history : 

  • The patient is a known case of chronic kidney disease for 2 years coming for regular maintenance dialysis once every two weeks.
  • He is also a known case of hypertension for 2 years.
  • He is a known case of Calcemic uremic arteriopathy.

GENERAL EXAMINATION

The patient is conscious, cooperative, and coherent

He is well oriented to time place and person.

He is of average built and moderately nourished.

He has no pallor, icterus, cyanosis, clubbing, or generalized lymphadenopathy

He has bilateral pedal edema- pitting type, extending up to the ankle joint.



Vitals

  • Pulse: 92 beats per min, right radial pulse, regular, normal volume
  • Blood pressure: 140/100 mmHg, measured on the right upper arm in sitting position
  • Respiratory Rate:  116 cycles per min 
  • SPO2 at room temp. : 98%
  • GRBS: 86 mg%
  • Temperature: Afebrile 

SYSTEMIC EXAMINATION

Abdominal system

  • Normal oral mucosa
  • No scars, sinuses, or any engorged veins.
  • Hernial orifices intact
  • Tenderness or guarding absent
  • No enlargement of liver, kidneys, or spleen
  • No ascites
  • Bowel sounds were normal.
Cardiovascular system
  • cardiac sounds  s1 and s2 heard normally
  • Apex beat located in 5th ICS, medial to the mid-clavicular line.
  • No cardiac murmurs
  • Thrills absent

Respiratory system 

  • No chest wall deformity 
  • Trachea central
  • Expansion is symmetrical
  • Percussion note is resonant
  • Breath sounds normal, no wheeze or crackles heard.
  • Vocal resonance normal and symmetrical

central nervous system

  • Higher mental functions intact 
  • Cranial nerves II- XII: Pupils equal and reactive to light, No abnormality detected.
  • Speech normal




  • POWER

    RIGHT

    LEFT

    UL

    LL

    UL

    LL

    5

    5

    5

    5

    TONE

    NORMAL

    NORMAL

    NORMAL

    NORMAL

    LIGHT TOUCH

    NORMAL

    NORMAL

    NORMAL

    NORMAL

    POSITION

    NORMAL

    NORMAL

    NORMAL

    NORMAL

    COORDINATION

    NORMAL

    NORMAL

    NORMAL

    NORMAL


Musculoskeletal system
  • Gait cannot be assessed
  • No muscle or soft tissue changes.
  • No bone or joint deformities.
  • No limitation of movements.

PROVISIONAL DIAGNOSIS 

?Heart failure

?Chronic liver disease

?Nephrotic syndrome

?Hypothyroidism

Investigations

The following tests have been ordered and the results are awaited

1. Complete blood count 

2. Urine routine/microscopy and renal function test

3. Liver function test 

4. Serum total protein and albumin 

5. Serum lipid profile 

6. Chest X ray, ECG and Brain natriuretic peptide 

7. Serum TSH 

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