1601006180 SHORT CASE

 

1601006180



A 45 year old male resident of Nalgonda labourer by occupation presented  with chief complaint of : 
• shortness of breath since 10 days  
• Cough since 8 days 
• swelling of legs since 8 days 


History of presenting illness  

Patient was apparently asymptomatic 10 days ago,then developed —
• Grade III  shortness of breath which was insidious in onset , nonprogressive,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 8days which is insidious in onset , non progressive ,no aggrevating and relieving factors 
•  Grade III bilateral Pedal edema  since 8 days which in insidious in onset , gradually progressive,pitting type , no aggravating and no relieving factors 
        .      fever since 8 days which is insidious in onset ,with evening rise of temperature , intermittent , not associated with chills and rigors , headache , vomiting 
• 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 

•  decreased appetite 
• Mixed diet
• Regular bowel habits and normal 
• 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 

 GENERAL EXAMINATION 

   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 hg measured in sitting position on right upper arm 
⁃ Respiratory rate : 20cpm
⁃ Afebrile 
 
RESPIRATORY SYSTEM EXAMINATION 
 
 Patient is examined in supine aswell 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 : RR -20cpm                  .  
                         Type - abdomino thoracic.                        
  .                      Equal on both sides 
⁃ 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 
  1. Direct percussion: resonant on clavicle , sternum 
    2.   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 




    




 

Provisional diagnosis :ACUTE ON CHRONIC  RENAL Failure with bilateral Pleural Effusion
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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