1601006156 SHORT CASE

 

SHORT CASE-1601006156

Hall ticket number:1601006156

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A 45 year old male,resident of Nalgonda who is a  labourer by occupation presented to the opd with chief complaints of : 

•Fever since 10 days 

•Cough since 7days       

        •Shortness of breath since 7 days

        •Decreased urine output since 5 days

        •Bilateral pedal edema since 5 days

 

History of present illness:

The patient was apparently asymptomatic 2 years ago then he developed:

Fever and productive cough lasting for 2 weeks, for which he visited a hospital and was diagnosed with tuberculosis.He took ATT for 6 months.

Thereafter he didn't have any complaints of cough or fever.

Course of illness in the patient:

Now he presented with the following complaints:

     1.Fever since 10 days

• Intermittent type
• Associated with evening rise of temperature 
• Not associated with chills and rigor

      2.Shortness of breath since 7 days

• MMRC-grade 3.
• Aggravated by walking and doing strenuous activity and relieved in sitting position. 
• History of orthopnea present. 
• No history of PND.

      3.Dry Cough since 7 days.No postural or diurnal variation is present.

     

     

      4.History of burning micturition and oliguria is present since 5 days.

      5.Grade 3 bilateral pedal edema-pitting type.

There is no history palpitations, chest pain and hemoptysis. 

Past history:

• No history of diabetes,hypertension, asthma,epilepsy. 

Personal history:

• He takes a mixed diet.
• Decreased appetite. 
• Bowel habits are regular. 
• Patient has burning micturition and oliguria.
• Alcoholic since 1 year,drinks once weekly.
• Smoker since 25 years-smokes one pack of cigarette per day(25 pack years).

General examination:

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

• Pallor is present. 
• No signs of icterus,cyanosis, clubbing, koilonychia, generalized lymhadenopathy and pedal edema.

Vitals:

• Afebrile.
• Pulse rate-80 bpm,regular rhythm,normal in volume.
• Blood pressure-130/80 mmHg,right arm in sitting position. 
• Respiratory rate-20 cpm.

Respiratory system examination:

Inspection:

• Trachea appears to be central.
• No visible apical impulse.
• Shape of the chest-normal.
• Symmetrical. 
• Trail sign is negative. 
• Abdomino-thoracic type of respiration-equal on both sides.
• No use of accessory muscles of respiration. 

Palpation:

• All the inspectory findings are confirmed. 
• Trachea is central.
• Apex beat-5th ICS,medial to the midclavicular line. 
• Decreased chest expansion. 
• Vocal fremitus.

Region	Right	Left
Supraclavicular	Normal	Normal
Infraclavicular	Normal	Normal
Suprascapular	Normal	Normal
Interscapular	Normal	Normal
Infrascapular	Decreased	Decreased
Mammary	Normal	Normal
Infrasmammary	Normal	Normal
Axillary	Normal	Normal
Infraaxillary	Decreased	Decreased

Percussion:

Direct:resonant over sternum and clavicle. 

Indirect:

Anterior 

• Resonant in supraclavicular,infraclavicular and inframammary areas on both sides.
• Traube's space-dull.

Posterior 

• Resonant in suprascapular and interscapular areas.
• Dull in infrascapular areas of both sides.

Auscultation:

• Bilateral air entry present. 
• Normal vesicular breath sounds heard.
• Reduced breath sounds in bilateral infraaxillary and infrascapular areas.
• Fine crepitations heard in bilateral infraaxillary and infrascapular areas.

CVS and CNS examination is normal. 

Investigations:

Chest X-ray:

Bilateral pleural effusion.

Renal function test:

Urea-169 mg/dl

Creatinine-21.9 mg/dl

ABG Report:

Interpretation:

• PH-low-acidosis.
• PCO2-low-cannot explain the acidotic PH.
• Low HCO3-can explain the acidotic PH
• Metabolic acidosis

Hemogram:

ECG:

Provisional diagnosis:

• Bilateral pleural effusion with past history of tuberculosis. 
• Acute on chronic renal failure.

Treatment:

• Salt and fluid restriction. 
• Injection lasix 40mg BD.
• Tab.shelcal 500mg OD.
• Tab.nodosis 500mg BD.
• Nebulization with mucomist and budicort 12th hrly.
• BP,pulse and SpO2 monitoring. 
• Input and output charting.