1601006084 LONG CASE

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HALL TICKET :1601006084

A 45 year old male resident of Nalgonda labourer by occupation presented  with chief complaint of : 

• shortness of breath since 10 days  

• Cough since 10 days 

• Pedal edema since 10 days 

History of presenting Illness:-

Patient was apparently asymptomatic 10 days ago,then developed —

• Grade III  shortness of breath which was insidious in onset , nonprogressive,aggravated by walking  and strenous work  and dressing , relieved by sitting             

               There is history of orthopnea                        

               There is no history of PND 

• Dry Cough  since 10days which is insidious in onset , non progressive ,no aggrevating and relieving factors 

•  Grade III bilateral Pedal edema  since 10 days which in insidious in onset , gradually progressive,pitting type , no aggravating and no relieving factors 

        .      Fever since 10 days which is insidious in onset ,with evening rise of temperature , intermittent , not associated with chills and rigors , headache , vomiting 

• History of burning micturition and oliguria since 5 days 

• There is no history of sweating , palpitations , chestpain , hematuria 

Past history 

•    2 years back he developed symptoms of  productive cough and fever for 1 week for which he visited to hospital and diagnosed with TUBERCULOSIS and took  antitubercular drugs for 6 months and at that time he was told be having some kidney issues and used some medications ( records notavailable ) 

• Not a known case of diabetes ,hypertension,asthma , convulsions

• Surgical history is not significant.      

Family history 

          Not significant 

Personal history 

•  decreased appetite 

• Mixed diet

• Regular bowel habits and normal 

• Patient has oliguria and burning micturition 

• He is an alcoholic since 10 years  , drinks once   weekly 

• Smoker since 25 years , he smokes daily 2-5 beedis 

 GENERAL EXAMINATION 

   Patient is conscious coherent and cooperative  , moderately built , moderately nourished 

⁃ Presence of pallor 

⁃ No icterus , no cyanosis, no clubbing ,no pedal edema 

⁃ No generalized lymphadenopathy     

 

 Vitals 

⁃ Pulse taken  in sitting position ,left radial pulse ,Pulse rate : 80bpm , regularly regular 

⁃ Bp 130/80 mm hg measured in sitting position on right upper arm 

⁃ Respiratory rate : 20cpm

⁃ Afebrile 

 

RESPIRATORY SYSTEM EXAMINATION 

 

 Patient is examined in supine aswell as in sitting positions under well ventilated room with consent taken 

 Upper respiratory tract :

     nose , oral cavity  are examined and no abnormal findings are present 

 examination of chest proper :

• Inspection 

⁃ shape of chest : normal 

⁃ Symmetry of chest : symmetrical 

⁃ Trial sign negative 

⁃ Movements of chest : RR -20cpm                  .  

                         Type - abdomino thoracic.                        

  .                      Equal on both sides 

⁃ No involvement of accessory muscles and no intercoastal tenderness 

⁃ No visible scars , no sinuses , no engorged veins 

⁃ No deformities of spine 

⁃  No visible apical impulse 

• palpation 

⁃ No tenderness and no local rise of temperature 

⁃ Inspectory findings are confirmed

⁃ Trachea central 

⁃ Apex beat : felt at 5 th Intercoastal space  medial to mid clavicular line

⁃ Decreased  chest expansion 

⁃ Vocal fremitus : decreased  at infra axillary and infra scapular areas on both sides                                       normal on supra clavicular , infraclavicular ,mammary , infra mammary , suprascapular and interscapular areas 

.

•   Percussion 

1. Direct percussion: resonant on clavicle , sternum 

    2.   Indirect percussion : 

  Anterior :

⁃   resonant in supra clavicular area 

⁃ Resonant in infraclavicular  area 

⁃ Resonant  in inframammary area on both sides 

⁃ Traube’s space:dull  

  Posterior :

⁃ Resonant in suprascapular area 

⁃ Resonant in interscapular area 

⁃ Dull in Infrascapular area on both sides 

• Auscultation   

⁃ Bilateral air entry present 

⁃ Normal vesicular breath sounds heard 

Reduced in  B/ L infrascapular  and infra axillary areas 

        -       fine crepts heard on B/L infra axillary and infra scapular areas 

 

CVS EXAMINATION 

 

⁃   S1 s2 heard 

⁃ No murmurs 

⁃ No palpable  thrills 

ABDOMINAL EXAMINATION 

 Scaphoid shape 

No tenderness 

No palpable mass 

No hepatosplenomagaly 

No ascites 

Bowel sounds  present 

CNS EXAMINATION 

⁃  Conscious and alert 

⁃ Normal gait 

⁃ Normal speech 

⁃ No signs of meningeal irritation 

⁃ Cranial nerves , motor system , sensory 

⁃ Reflexes : superficial and deep tendon reflexes are intact 

INVESTIGATIONS 

⁃ CBP

⁃ CUE

⁃ Abg 

⁃ RFT 

⁃ LFT

⁃ PT

⁃ APTT

⁃ Blood sugar 

⁃ ESR 

⁃ Serum pottasium 

⁃ Blood culture 

⁃ Chest x ray 

⁃ Ecg 

⁃ Ultrasound abdomen 

    

 

Provisional diagnosis :ACUTE ON CHRONIC  RENAL FAILURE with pleural effusion and  past history of  PULMONARY TUBERCULOSIS .

TREATMENT 

⁃ Salt and fluid restriction 

        Salt - < 2 g/ day 

        Fluid - < 1 lt / day 

⁃ Injection  iv LASIX 40mg BD 

⁃ Tab NODOSIS  500mg bd 

⁃ Tab SHELCAL 500mg od

⁃ Input and output charting 

⁃ Bp  pulse  spo2 charting