1601006062 LONG CASE

 28 YEAR OLD GENTLEMAN WITH FEVER,SOB,PEDAL EDEMA, ABDOMINAL DISTENSION AND DECREASED URINE OUTPUT.


Hello everyone, I am a final year medical student. Recently I came across an interesting case in my clinical rotations.

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 


This E log book also reflects my patient-centered online learning portfolio. Your valuable inputs on the comment box is welcome.
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.


 CHIEF COMPLAINTS: A 29 year old male unmarried who is a daily wage labourer resident of Nalgonda, came to hospital with chief complaints of on & off fever since 2 yrs , shortness of breath , b/l pedal edema , abdominal distension and decreased urine output since 1 year

HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 2years ago and then one day he developed 
fever (high grade , continuous , associated with chills & rigors) and generalized body aches for which he went to a local RMP and he prescribed some tablets.
Fever subsided temporarily and he used to get fever at night.

So he went to a local hospital in nalgonda where they prescribed him some pain killers for his body pains & fever which he continued to take daily for nearly 5-6 months (2-3 tablets/day).

Inspite of that he had on & off fever & pedal edema(b/l pitting type extending upto knees) for which he went to NIMS,where several investigations where performed. He then underwent kidney biopsy due to abnormal RFT's and was diagnosed with primary focal segmental glomerulo sclerosis.

2 months later he had increasing pedal edema associated with decreased urine output , abdominal distension and SOB grade 2-3, for which dialysis was advised & that was when he came to our hospital. From then onwards he was on maintainence hemodialysis.

He has also been started on empirical ATT even though his sputum turned out to be negative because of the long standing history of fever, cough and around 10 kgs of weight loss in 7 months. After initiating ATT, his blood pressure couldn't be under control so decision was made to put Rifampicin on hold.

From the past 5-6 months SOB has been increasing gradually to grade-4 with associated orthopnea & PND.

No h/o chest pain/palpitations/chest tightness
No h/o fever/cough at present
No other complaints

PAST HISTORY:

Hypertension since 1 year
No h/o DM/ asthma/epilepsy/CAD

PERSONAL HISTORY :
Mixed diet
Disturbed sleep
Decreased appetite
Normal bowel & bladder habits
No addictions

FAMILY HISTORY:
No relevant family history seen .

GENERAL EXAMINATION:
Patient is conscious , coherent and cooperative.
Oriented to time, place and person.
He is moderately built and moderately nourished.

VITALS:
Temperature: afebrile 
Blood pressure: 130/90mm Hg
Resp rate:12 cycles per min 
Pulse rate : 82bpm
Pallor : Present


Icterus : absent
Clubbing: not present
Koilonychia: not present 
Lymphedenopathy: not present 
Edema : present in lower limbs 



GENERAL INSPECTION :
JVP raised 
Scar of failed AV fistula - arterialization of veins 


So they planned dialysis on femoral vein
CVS EXAMINATION:
INSPECTION:
Examination of neck
Carotids : bilaterally visible 
JVP : elevated 
Trachea in the midline
Visible apex beat 

PALPATION:
Trachea midline 
No carotid bruit
thrill present at tricuspid area 
Palpable P2
Apex beat :At left 6th intercostal space lateral to midclavicular line
No suprasternal ,epigastric and Interscapular impulses.

PERCUSSION:
Rt heart border corresponding to rt sternal border
Rt & lt 2nd intercostal spaces are resonant.

AUSCULTATION:
S1 S2 heard 
P2 loud
High pitched grade 4 Pansystolic murmur heard on mitral and tricuspid area.

ABDOMINAL EXAMINATION:
Distended abdomen 
Umbilicus everted
shifting dullness/fluid thrill present


No visible scars/sinuses/pulsations
No tenderness
No organomegaly
Bowel sounds heard 

RESPIRATORY SYSTEM EXAMINATION:
Elliptical & bilaterally symmetrical chest
Both sides moving equally with respiration
Resonant note heard in all areas
Bilateral air entry present
Normal vesicular breath sounds
Fine crepitations heard in right infra axillary & infra scapular areas

CENTRAL NERVOUS SYSTEM EXAMINATION:
Higher mental functions intact
Sensory & motor system normal
Cranial nerves intact
Reflexes present
No focal neurological deficit

LAB INVESTIGATIONS:
Complete blood picture 
HEMOGLOBIN : 7.7g/dl


RENAL FUNCTION TESTS :


RFT interpretation: urea ,creatinine and uric acid levels are elevated .
Random blood sugar are in normal range.


CHEST X RAY:


ULTRASONOGRAPHY ABDOMEN


ELECTROCARDIOGRAPHY:



Left axis deviation and left ventricular hypertrophy are interpreted on ECG.

DIAGNOSIS:   Based on the history,clinical features , examination and laboratory findings my diagnosis is
CHRONIC KIDNEY DISEASE WITH HEART FAILURE.

MEDICATIONS:
7am - T Nicardia 20mg ( nifidipin)
Arkamine 0.1mg (clonidine)
Met XL 50mg ( metoprolol succinate)
Lasix 80mg ( furosemide)
Spironolactone 25mg 

Between 1:30 - 2pm
T Arkamine 0.1mg
Nicardia 20mg

6pm
T Lasix 80mg

8pm
T Arkamine 0.1mg
Met XL 50
Lasix 80mg
Spironolactone 25mg
Nicardia 20mg
Shelcal 500mg ( calcium with vitamin D)

His blood pressure observation after starting medications


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