1601006164 LONG CASE

 

LONG CASE 1601006164

LONG CASE 
April 28 ,2021

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A 45 years old gentleman from Ramanthapur who is farmer by occupation came to hospital with

CHIEF COMPLAINT 
- shortness of breath since 1 year
- swelling of both feet ankle and legs in 3 months 

History of presenting illness
Patient was apparently asymptomatic 1 year back then he developed
1. Shortness of breath
     - insidious in onset 
      - duration 1 yr
      - gradually progressive

       - orthopnea since 1month 
       
       Breathlessness increased on lying down position which was reviewed on sitting in upright position
     
   2. Swelling of both feet ankle legs
      - insidious in onset 
       - duration 3 months
     
       - gradually progressive starting in feets and ankle and progressive legs up to level of knees
       - aggravated on walking and less on elevation of legs 
       
         ** other complaints
        - decrease in urine output since 1 month
        - there is history of weight loss
        - 
         - there is no history of chest pain palpitation or syncopal attack
            
         - No history of fever sore throat joint pain and no history of hemoptysis or wheezing
          - no history of bluish discoloration of face or  oral cavity
           - new history of pain in abdomen or Jaundice


     PAST HISTORY 
   
    - he was diagnosed with hypertension 2 years back and prescribed nicardia 20mg . But he discontinued medication taking since 1 year
   
 - he was met with the road traffic accident 3 years back underwent surgery on his right leg he was taking analgesic regularly for 1  year
 
- he was diagnosed with CKD and is on dialysis since one month

- no history of diabetes mellitus tuberculosis asthma and epileps

 PERSONAL HISTORY 

- he takes a mixture diet
 - his appetite is normal 

 - sleep is disturbed because of orthopnea  and breathlessness is relieved in semi recumbent position
 - decrease in urine output since 1 month
- Bowel movements of regular
- consumed alcohol occasionally since 20 years

FAMILY HISTORY 

- No history of similar complaints HTN ,DM,,TB in FAMILY

TREATMENT HISTORY 
History of usage of analgesics for 1 year 
Nicardia 20 mg HTM 

GENERAL EXAMINATION 
 
Patient is conscious coherent and co-operate to moderately built and moderate nourished

Parlor present 
- no signs of icterus cyanosis clubbing koilonychia or lymphadenopathy 

- bilateral pedal edema present extending  up to level of knees

Pitting type of edema 

Grade 3 (about 5mm depression taking more than 30 sec to rebound )

Arterio venous fistula for hemodialysis is present on left forearm with palpable thrill

VITALS 
PR- 84bpm regular normal volume 
Bp- 130/80 hg right arm sitting position
RR- 23 cpm 
TEMP-a febrile 

CARDIOVASCULAR SYSTEM EXAMINATION 
 - shape of chest normal
- trachea appears to be in mid line
- visible apical impulse is present lateral to the midclavicular line 
- no engorged veins on chest 
- No scars or sinuses are visible 

- no visible epigastric pulsatio
-JVP raised 
 
Palpation

All the inspectory finding for confirmed
- apex beat is left 5 th intercostal space ,5cm lateral to midclavicular line 
- apex beat is heaving 
- no palpable murmurs
- carotid artery pulsation normal

Percussion 
right heart Borger shifted 1cm right from right eternal 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 so uses ,scars or visible pulsation 
 
Hernia orifice are free 
PALPATION 
No local rise of temperature

No tenderness
 
No guarding or rigidity 
 No palpable masses


PERCUSSION 
shifting dullness present 
Liver span normal 

Auscultation
Bowel sounds heard 



Respiratory system examination
Bilateral air entery present 
Normal VESICULAR breath sounds heard 
Basal crepetations  present in both lung field 


Central nervous system normal


Investigations

Complete blood picture

Hemoglobin reduced

PCV reduced 
RBC count reduced 

Complete Urine Examination
Albumin in urine

 x-ray
Serum urea and creatinine raised
 liver function test
 serum iron
USG abdomen 

Grade 2 renal parenchymal disease
 treatment

Salt and fluid restriction 

Tab.nicardia10mg T.I.D
Tab .lasix 40mg B.I.D
Tab. Arkamin 100mg 
Tab. Unifer 
Capsule gel cal D3
 provisional diagnosis
Heart failure with chronic kidney disease

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