1601006175 LONG CASE

 1601006175 long case

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A 45 year old male patient who’s a farmer by occupation came to OPD with
Chief complaints :
Shortness of breath since 2 years 
Decreased urine output since 2 years 
Pedal edema since 2 years 
History of present illness : 
Patient was apparently asymptomatic 2 years ago then he developed ,shortness of breath which was insidious in onset gradually progressive, which progressed to the present stage (from class 2 progressedto class 4 ) there were ,no relieving factors. He also had bilateral pedal edema since 2 years which was also insidious in onset and gradually progressive , presently he is having grade 4 pitting type of bilateral pedal edema till below knee ,which did not relieved on rest or medication. There was also decrease in urine output since 2 years, he passed urine daily once which was  scanty in amount , there was n burning micturition or dysuria.
Along with these symptoms he also had loin pain which was continuous & not radiating type . Due to his illness he has not been working since 2 years. All these symptoms persisted even after his regular sessions of dialysis ( twice weekly ) and this time they have become even more serious and was admitted in the hospital. 
Past history:
The patient is a known case of hypertension since 12 years for which he is taking medication regularly in since 2 years before which he was taking irregular medication.
No history of 
Diabetes mellitus, tuberculosis , bronchial asthma, epilepsy
Family history: not significant 
Personal history : 
diet : mixed
Appetite : reduced 
Bowel movemets: regular
Bladder movements : irregular 
Sleep : decreased
Addictions : nil
Drug history: 
Before 2 years he was taking irregular medication- telvas 40 mg OD 
Presently he is using Nicardipine prolonged release tablets 20 mg , metoprolol succinate extended release 25mg .
General examination:  
The patient was conscious, coherent & cooperative , ill built & undernourished.
There were signs of pallor 

bilateral pedal edema 

There were no signs of icterus , clubbing , cyanosis , koilonychia & lymphadenopathy 
Vitals : 
Temperature: afebrile 
Pulse : 64 bpm regular ,normal volume 
Blood pressure: 120/80
Respiratory rate: 21 cpm abdominothoracic 
Systemic examination: 
Abdominal examination: 
Inspection : localised asymmetrical fullness in the left lumbar region 
                   Umbilicus central in location and slightly retracted.

Abdomen was moving accordingly with respiration. 
No visible pulsation , no visible gastric peristalsis, no visible scars and sinuses
Palpation: 
No local rise of temperature. No organomegaly.
Percussion : 
Dull note in the flanks & tympanic note in the centre ( around the umbilicus) 
Auscultation: 
Normal bowel sounds were heard. 
Respiratory examination: 
Inspection: 
Trachea is central in position. Shape of the chest elliptical . Bilaterally equal chest movements with respiration. There was supra scapular hollowness .
No scars and sinuses
Palpation: 
No local rise of temperature. All the inspectory findings were confirmed 
Trachea is in central position.
Apex beat is in 6 th intercostal space lateral to mid clavicular line.

Decreased TVF in right inframammary/infraaxillary/infrascapular areas.

Chest expansion was normal.
Percussion:
On direct percussion of clavicle- 
2nd to 5th intercostal space on right side & 2nd to 6 th intercostal space on the left side - resonant note

Dull note in right infraaxillary/infrascapular areas.
Auscutation: normal vesicular breath  sounds heard

Decreased BS in right inframammary/infraaxillary/infrascapular areas.

Cardiac examination:
There was no precordial bulge on inspection .

Apex beat in 6th ICS lateral to MCL

S1 & s2 were heard in mitral , tricuspid, aortic & pulmonary areas .no added sounds were heard. 
Cns examination: no facial asymmetry , all the reflexes were normal
INVESTIGATIONS : 

                                      
ECG 




X-ray 

Provisional diagnosis : chronic kidney disease with maintenance dialysis.

Drugs used -