1601006140 SHORT CASE

 

1601006140, short case

A 45 year old gentleman,from ramanapet who is a farmer by occupation came to the hospital with the chief complaints of:

• Shortness of breath since 1 year.

• Swelling of both feet, ankles and legs since 3

months.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 year back then he developed:

1. Shortness of breath

• Insidious in onset..

• Duration-1 year.

• Gradually progressive(initially grade 2 NYHA, and has gradually progressed to breathlessness at rest-grade 4 NYHA). • Orthopnea since 1month

Breathlessness increases on lying down position which was relieved on sitting in upright position.

• Associated with paroxysmal nocturnal

dyspnea.

2.Swelling of both feet, ankles and legs

• Insidious in onset.

• Duration-3 month

• Gradually progressive (started in feet and ankles and progressed to legs upto the level of knees). 

Aggravated on walking and less on elevating the legs.

=~ Other complaints:

• Decrease in urine output since 1 month.

PAST HISTORY:

• He was diagnosed with hypertension 2 years back and is prescribed Nicardia 20 mg. But he discontinued taking medication since 1 year.

• He is diagnosed with CKD and is on dialysis since 1 month.

• No history of diabetes mellitus, tuberculosis, asthma and epilepsy.

GENERAL EXAMINATION:

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

Pallor-present.

• No signs of icterus,cyanosis, clubbing,koilonychia or lymphadenopathy.

• Bilateral pedal edema present extending upto the level of knees

Pitting type of edema.

Grade 3(about 5 mm of depression taking more than 30 seconds to rebound). 

Arteriovenous fistula for haemodialysis is present on left forearm with palpable thrill.

CARDIOVASCULAR SYSTEM examination: 

INSPECTION:

•Shape of the chest normal.

• Trachea appears to be in midline.

• Visible apical impulse is present lateral to the midclavicular line.

• No engorged veins on the chest.

• No scars or sinuses are visible.

• No visible epigastric pulsations.

 • JVP is raised

 PALPATION:

• All the inspectory findings are confirmed.

• Apex beat is in left 5th intercostal space,5cm lateral to the midclavicular line.

• Apex beat is heaving??

• No palpable murmurs.

• Carotid artery pulsations normal,no thrill present.

PERCUSSION:

Right heart border shifted 1 cm right  from the right sternal border.

Left heart border shifted 4 to 5 cm lateral to midclavicular line.

AUSCULTATION: 

S1 & S2 : heard

 

No Murmurs 

Per Abdomen:

Inspection-

Abdomen- distended 

Umbilicus -Central in position and slit like

flanks are full

no sinuses, scars or visible pulsations 

hernial orifices are free.

Palpation :

no local rise in temperature 

no tenderness 

no guarding and rigidity 

no palpable masses.

Percussion:

shifting dullness- present

liver span-normal

Auscultation:

bowel sounds are heard.

Respiratory system :

bilateral air entry- present

normal vesicular breath sounds heard 

basal crepitations present in both the lung fields.

Central nervous system- normal.

INVESTIGATIONS:

CBP- 

Hemoglobin- reduced

X-RAY:

USG ABDOMEN:

Grade-II renal parenchymal disease

TREATMENT: 

Salt and fluid restriction

Tab. Nicardia 10mg T.I.D

Tab. Lasix 40mg B.D

Tab. Arkamin 100mg

PROVISIONAL DIAGNOSIS:

HEART FAILURE WITH CHRONIC KIDNEY DISEASE.