1601006177 LONG CASE

 1601006177

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment.

LONG CASE

A 29 yrs old male AC technician by occupation hailing from Nalgonda came to the hospital with CHIEF COMPLAINTS OF:

1. Fever which is on and offsince 2 yrs 

2.Shortness of breath 

3. B/Lpedal edema 

4 .Abdominal distension and 

5.Decreased urine output since 1 year.

History of presenting illness

Patient was apparently asymptomatic 2 years back then he developed fever and generalized body pains. Fever was high grade and was associated with chills and rigor. For this he had visited local RMP where he was prescribed with some medication. With that medications fever subsided.

After few months again he developed fever and body pain for which he visited a hospital in Nalgonda. There he was prescribed with pain killers which he used for 6 months (daily). 

In spite of using medications, he used to develop on and off fever. He also developed pitting type of pedal edema (extending up to knee). He visited NIMS hospital where he was diagnosed with hypertension and renal failure. He was prescribed with some medication. 

Two months after visiting NIMS, he again had increased pedal edema along with decreased urine output, abdominal distension and shortness of breath.

    Pedal edema- pitting type, extending up to knee

    Decreased urine output- Passes urine once daily

    Shortness of breath- Grade 3

For this he was advised to have dialysis. From then onwards he is under Maintenance hemodialysis

Course of illness

No history of palpitations

No history of chest tightness/chest pain

No history of cough

No history of yellowish discoloration of sclera

No history of burning micturition and fever.

Past history

He was diagnosed with hypertension one year back.

No history of diabetes mellitus, bronchial asthma and tuberculosis.

Family History

No history of similar complaints in family.

No history of diabetes mellitus, bronchial asthma and tuberculosis.

Personal History

Diet: Mixed

Appetite: Decreased

Sleep: Inadequate

Bowel Movements: Regular

Bladder: Decreased urine output

No known allergies

No addictions

General Examination

Patient is conscious, coherent and cooperative. Oriented to time, place, person, Moderately built and moderately nourished.

Vitals:

Temperature:  Afebrile

Pulse rate: 80bpm regular, normal in volume and character. There is no radio-radial or radio-femoral delay.

Respiratory rate: 18 cycles/min

Blood pressure: 130/80 mm Hg in left arm in supine position

Pallor: Present

Icterus: Absent

Clubbing: Absent

Koilonychia: Not present

Lymphadenopathy: Absent

Edema: Present

CVS Examination

Inspection

• Chest wall appear symmetrical
• JVP - elevated
• Carotid pulsations: Bilaterally visible
• Trachea appears to be in midline
• Visible Apex beat

• Scars present

• No sinuses, engorged

Palpation

• Trachea midline
• No carotid thrill
• Palpable P2
• Apex beat: 6th intercostal space lateral to midclavicular line
• No epigastric pulsations
• No tenderness

Auscultation

• S1 heard
• S2 heard; Loud P2

Respiratory System

Inspection

• Trachea appears to be central
• Elliptical and bilaterally symmetrical chest

Palpation

• Trachea is central in position
• Both sides move equally with respiration
• No tenderness

Percussion

• Resonant note heard in all areas

Auscultation

• Normal vesicular breath sounds heard
• Bilateral air entry is present
• Fine crepitations are heard in Right infra axillary and infra scapular area

Abdomen Examination

Inspection

• Abdomen is distended
• Umbilicus is everted
• No scar, sinuses, visible pulsations

Palpation

• No local rise of temperature
• No tenderness
• No Organomegaly

Percussion

• Shifting dullness/fluid thrill is not present

Auscultation

• Bowel sounds heard

CNS Examination

• Higher mental functions intact
• Sensory system - Normal
• Motor system - Normal
• Cranial nerves intact
• No focal neurological deficit

Lab investigations

Complete Blood picture

Renal function test

ECG

Chest X-ray

Ultrasound Abdomen

Treatment

• Tab Nicardia 20mg QID
• Tab Lasix 40mg BD
• Tab Met.XL 50mg BD
• Tab Shelcal 500mg OD
• Tab Arkamine 0.2mg TID

Provisional Diagnosis

As patient has decreased urine output, pedal edema, shortness of breath, orthopnea, PND my anatomical diagnosis is kidney and heart pathology.

After performing investigations, patient is diagnosed with renal failure and heart failure.