1601006152 LONG CASE

 

Hallticket no:: 1601006152 generel medicine long case 29 year old male on & off fever since 2 yrs , shortness of breath , b/l pedal edema , abdominal distension and decreased urine output since 1 year







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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 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 


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.

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  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 .
Random blood sugar

Chest Xray:

ULTRASONOGRAPHY ABDOMEN

ELECTROCARDIOGRAPHY:


Left axis deviation and left ventricular hypertrophy are interpreted on ecg.
Instruments:


Medications :
Nefidipine
clonidine hydrochloride
Sodium bicarbonate
Shelcal 500mg 

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

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