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