1601006156 LONG CASE

 

LONG CASE-1601006156

 Hall ticket number-1601006156

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.

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 months
  • 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.
  • There is history of weight loss present (65kg to 58 kg).
  • There is no history of chest pain,palpitations or syncopal attacks.
  • No history of fever,sore throat and joint pains.
  • No history of hemoptysis and wheezing. 
  • No history of bluish discoloration of face/oral cavity. 
  • No history of pain abdomen/jaundice.
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 was met with a road traffic accident 3 years back,underwent a surgery on his right leg.He was taking analgesics regularly for 1 year.
  • He is diagnosed with CKD and is on dialysis since 1 month.
  • No history of diabetes mellitus, tuberculosis, asthma and epilepsy. 
PERSONAL HISTORY:
  • He takes a mixed diet.
  • His appetite is normal.
  • Sleep is disturbed because of orthopnea and breathlessness is relieved in semi-recumbent position. 
  • Decreased urine output since 1 month.
  • Bowel movements are regular. 
  • Consumes alcohol occasionally since 20 years.
FAMILY HISTORY:
  • No history of similar complaints, hypertension, diabetes, TB in the family.
TREATMENT HISTORY:
  • History of usage of analgesics for a year.
  • Nicardia-20 mg for hypertension. 
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.


CVS 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. 
Palpation:
  • All the inspectory findings are confirmed. 
  • Apex beat is in left 5th intercostal space,5cm lateral to the midclavicular line.
  • No palpable murmurs.
  • Carotid artery pulsations normal,no thrill present. 
Auscultation:
  • S1,S2 heard.
PER ABDOMEN:
Inspection:
  • Generalized distention of the abdomen.
  • Umbilicus is displaced slightly downwards and is horizontal-slit like.
  • All the quadrants are moving equally with respiration.
  • No visible scars,sinuses or pulsations.
  • Hernial orifices are free.




Palpation:
  • No local rise of temperature. 
  • No tenderness/rebound tenderness is present. 
  • No guarding or rigidity present. 
  • No palpable masses.
  • Liver-lower border not palpable.
  • Spleen-not palpable. 
  • Fluid thrill absent. 
Percussion:
  • Shifting dullness present .
  • Liver-upper border-5th intercostal space in mid clavicular line.
  • Liver span-14 cm.
Auscultation:
  • Bowel sounds heard.
RESPIRATORY SYSTEM:

  • Bilateral air entry present. 
  • Normal vesicular breath sounds heard. 
  • Basal crepitations present.
CNS examination:
  • No abnormality detected. 
Investigations:

  1. Complete blood picture

Hemoglobin-7.6 gm/dl
PCV-Reduced
RBC count-Reduced

      2.Complete urine examination 

Albumin-3+(moderate proteinuria).
RBCs-2 to 4/HPF.

       3.Renal function test 

Urea-62 mg/dl
Creatinine-6.8 mg/dl

        4.Random blood sugar
        
        5.Liver function test



        6.Chest X-ray
        
       7.ECG
Rate-115 bpm
Rhythm-regular
Sinus tachycardia 
Leftward axis
          
       8.Serum iron


         9.USG-abdomen


PROVISIONAL DIAGNOSIS:

CHRONIC KIDNEY DISEASE WITH HEART FAILURE

TREATMENT:
  • Salt and fluid restriction 
  • Tab.nicardia 10 mg tid
  • Tab.lasix 20mg bd
  • Tab.arkamin 100 mcg
  • Tab.unifer
  • Cap.Gelcal D3

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