1601006174 LONG CASE

 

1601006174 LONG CASE



Long case presentation 

Consent is taken from patient and family members

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

1)shortness of breath since 10 days  

2)Cough since 9 days

3)Pedal edema since 9days 

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 10 days ago,then developed  

-Grade III  shortness of breath which was insidious in onset ,non progressive,aggravated by walking  and strenous work  and dressing , relieved by sitting             
-There is history of orthopnea                        
- There is no history of PND 

-Dry Cough  since 9days which is insidious in onset , non progressive ,no aggrevating and relieving factors 

-Grade III bilateral Pedal edema  since 9days which in insidious in onset , gradually progressive,pitting type , no aggravating and no relieving factors 
        
-History of burning micturition and oliguria since 5 days 

-There is no history of sweating , palpitations , chestpain , hematuria 

PAST HISTORY:
 - 2 years back he developed symptoms of  productive cough and fever for 1 week for which he visited to hospital and diagnosed with TUBERCULOSIS and took  antitubercular drugs for 6 months and at that time he was told be having some kidney issues and used some medications ( records notavailable ) 
-Not a known case of diabetes ,hypertension,asthma , convulsions
-Surgical history is not significant.      

FAMILY HISTORY:
- Not significant 

PERSONAL HISTORY:
-DIET : mixed 
-APETTITE: normal 
-Regular bowel habits 
-Patient has oliguria and burning micturition 
-He is an alcoholic since 10 years  , drinks once   weekly 
-Smoker since 25 years , he smokes daily 2-5 beedis 

 GENERALEXAMINATION:





  Patient is conscious coherent and cooperative  , moderately built , moderately nourished
-Presence of pallor 
-No icterus , no cyanosis, no clubbing ,no pedal edema 
-No generalized lymphadenopathy    









VITALS
-Pulse taken  in sitting position ,left radial pulse ,Pulse rate : 80bpm , regularly regular 
-Bp 130/80 mm Hgmeasured in sitting position on right upper arm 
-Respiratory rate : 20cpm
-Afebrile 


RESPIRATORY SYSTEM EXAMINATION:
 
 Patient is examined in supine a well as in sitting positions under well ventilated room with consent taken 

UPPER RESPIRATORY TRACT:

- Nose , oral cavity  are examined and no abnormal findings are present 

EXAMINATION OF CHEST PROPER:

Inspection:
-shape of chest : normal 
-Symmetry of chest : symmetrical 
-Trial sign negative 
-Movements of chest :equal on both sides
RR -20cpm                  
-Type - abdomino thoracic                 
- No involvement of accessory muscles and no intercoastal tenderness 
-No visible scars , no sinuses , no engorged veins 
-No deformities of spine 
-No visible apical impulse 


Palpation: 
-No tenderness and no local rise of temperature  -Inspectory findings are confirmed
-Trachea central 
-Apex beat : felt at 5 th Intercoastal space  medial to mid clavicular line
-Decreased  chest expansion 
-Vocal fremitus : decreased  at infra axillary and infra scapular areas on both sides                                       normal on supra clavicular , infraclavicular ,mammary , infra mammary , suprascapular and interscapular areas 

Percussion:

Direct percussion: resonant on clavicle , sternum 
Indirect percussion : 
  Anterior :
-Resonant in supra clavicular area 
-Resonant in infraclavicular  area 
-Resonant  in inframammary area on both                                      sides
          -Traube’s space:dull  
  Posterior :
-Resonant in suprascapular area 
-Resonant in interscapular area 
-Dull in Infrascapular area on both sides 

Auscultation:
-Bilateral air entry present 
-Normal vesicular breath sounds heard 
-Reduced in  B/ L infrascapular  and infra axillary areas 
                -Fine crepts heard on B/L infra axillary and infra scapular areas 
 
 CVS EXAMINATION:

-S1,S2 heard 
-No murmurs 
-No palpable  thrills 

ABDOMINAL EXAMINATION:

-Scaphoid shape 
-No tenderness
-No palpable mass 
-No hepatosplenomagaly 
-No ascites 
-Bowel sounds  present 

CNS EXAMINATION:

-Conscious and alert 
-Normal gait 
-Normal speech 
-No signs of meningeal irritation 
-Cranial nerves , motor system , sensory 
-Reflexes : superficial and deep tendon reflexes are intact 


INVESTIGATIONS:

-CBP
⁃CUE
-ABG 
-RFT 
-LFT
⁃PT
⁃APTT
⁃Blood sugar 
-ESR 
⁃Serum pottasium 
⁃Blood culture 
⁃Chest X ray 
-ECG 
⁃Ultrasound abdomen 


    






 



Provisional diagnosis :ACUTE ON CHRONIC  RENAL FAILURE  with pleural effusion with past history of  pulmonary TUBERCULOSIS 


TREATMENT:

-Salt and fluid restriction : Salt - < 2 g/ day ,Fluid - < 1 lt / day 
⁃Injection  iv LASIX 40mg BD 
⁃Tab NODOSIS  500mg bd 
⁃Tab SHELCAL 500mg od
⁃Input and output charting 
⁃Bp ,pulse ,spo2 charting 

 






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