1601006086 LONG CASE

 

1601006086 long case



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. 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 and your valuable inputs on the comment

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

History of present 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 he was diagnosed as hypertensive & renal failure.

2 months later he had increased pedal edema associated with decreased urine output , abdominal distension and SOB grade 2-3 for which dialysis was advised & he came to our hospital.

From then he was on maintainence hemodialysis.

From past 5-6 months SOB increased 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.

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 limbs to


GENERAL INSPECTION:
JVP raised 

Scars are present 


Scar of failed AV fistula - arteriorisation of veins 
So they planed dialysis on femoral vein


CVS:
INSPECTION:
Examination of neck
Carotids : bilaterally visible 
JVP : elevated 
Trachea in the midline
Visible apex beat 





Palpation
Trachea midline 
No carotid thrill
thrill present at  tricuspid area 
Palpable P2
Apex beat :At left 6th intercostal space lateral to midclavicular line

Palpation and locating apex beat 



No suprasternal ,epigastric and Interscapular impulses.

PERCUSSION:
Rt heart border corresponding to rt sternal border
Left Heart border corresponding to line joining apex in left 6th intercostal space
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 

Abdomen examination:
Distended abdomen 
Umbilicus everted


No visible scars/sinuses/pulsations
No tenderness
No organomegaly
No shifting dullness/fluid thrill 
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 crepts 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 : 8.3g/dl
RENAL FUNCTION TESTS :

Rft interpretation: urea ,creatinine and uric acid levels are elevated .
ELECTROCARDIOGRAPHY:
Left axis deviation and left ventricular hypertrophy are interpreted on ecg.

Chest Xray:

ULTRASONOGRAPHY ABDOMEN
Medications :
Nefidipine

clonidine hydrochloride

Shelcal 500mg 

Provisional diagnosis :
Based on the above findings decreased urine output ,mild ascites,shortness of breath ,my diagnosis is  related to kidney and heart pathology clinically. 
On lab  investigations my diagnosis is 
 Chronic kidney disease with heart failure.



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