LONG CASE 1601006164

LONG CASE 

April 28 ,2021

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A 45 years old gentleman from Ramanthapur who is farmer by occupation came to hospital with

CHIEF COMPLAINT 

- shortness of breath since 1 year

- swelling of both feet ankle and legs in 3 months 

History of presenting illness

Patient was apparently asymptomatic 1 year back then he developed

1. Shortness of breath

     - insidious in onset 

      - duration 1 yr

      - gradually progressive

       - orthopnea since 1month 

       

       Breathlessness increased on lying down position which was reviewed on sitting in upright position

     

   2. Swelling of both feet ankle legs

      - insidious in onset 

       - duration 3 months

     

       - gradually progressive starting in feets and ankle and progressive legs up to level of knees

       - aggravated on walking and less on elevation of legs 

       

         ** other complaints

        - decrease in urine output since 1 month

        - there is history of weight loss

        - 

         - there is no history of chest pain palpitation or syncopal attack

            

         - No history of fever sore throat joint pain and no history of hemoptysis or wheezing

          - no history of bluish discoloration of face or  oral cavity

           - new history of pain in abdomen or Jaundice

     PAST HISTORY 

   

    - he was diagnosed with hypertension 2 years back and prescribed nicardia 20mg . But he discontinued medication taking since 1 year

   

 - he was met with the road traffic accident 3 years back underwent surgery on his right leg he was taking analgesic regularly for 1  year

 

- he was diagnosed with CKD and is on dialysis since one month

- no history of diabetes mellitus tuberculosis asthma and epileps

 PERSONAL HISTORY 

- he takes a mixture diet

 - his appetite is normal 

 - sleep is disturbed because of orthopnea  and breathlessness is relieved in semi recumbent position

 - decrease in urine output since 1 month

- Bowel movements of regular

- consumed alcohol occasionally since 20 years

FAMILY HISTORY 

- No history of similar complaints HTN ,DM,,TB in FAMILY

TREATMENT HISTORY 

History of usage of analgesics for 1 year 

Nicardia 20 mg HTM 

GENERAL EXAMINATION 

 

Patient is conscious coherent and co-operate to moderately built and moderate nourished

Parlor present 

- no signs of icterus cyanosis clubbing koilonychia or lymphadenopathy 

- bilateral pedal edema present extending  up to level of knees

Pitting type of edema 

Grade 3 (about 5mm depression taking more than 30 sec to rebound )

Arterio venous fistula for hemodialysis is present on left forearm with palpable thrill

VITALS 

PR- 84bpm regular normal volume 

Bp- 130/80 hg right arm sitting position

RR- 23 cpm 

TEMP-a febrile 

CARDIOVASCULAR SYSTEM EXAMINATION 

 - shape of chest normal

- trachea appears to be in mid line

- visible apical impulse is present lateral to the midclavicular line 

- no engorged veins on chest 

- No scars or sinuses are visible 

- no visible epigastric pulsatio

-JVP raised 

 

Palpation

All the inspectory finding for confirmed

- apex beat is left 5 th intercostal space ,5cm lateral to midclavicular line 

- apex beat is heaving 

- no palpable murmurs

- carotid artery pulsation normal

Percussion 

right heart Borger shifted 1cm right from right eternal border 

Left heart border shifted 4 to 5 cm lateral to midclavicular line 

AUSCULTATION 

S1 s2 heard

 no murmurs 

Per abdomen 

INSPECTION 

 

Abdomen- distended 

Umbilicus central in position and slit like 

- flanks are full 

 No so uses ,scars or visible pulsation 

 

Hernia orifice are free 

PALPATION 

No local rise of temperature

No tenderness

 

No guarding or rigidity 

 No palpable masses

PERCUSSION 

shifting dullness present 

Liver span normal 

Auscultation

Bowel sounds heard 

Respiratory system examination

Bilateral air entery present 

Normal VESICULAR breath sounds heard 

Basal crepetations  present in both lung field 

Central nervous system normal

Investigations

Complete blood picture

Hemoglobin reduced

PCV reduced 

RBC count reduced 

Complete Urine Examination

Albumin in urine

 x-ray

Serum urea and creatinine raised

 liver function test

 serum iron

USG abdomen 

Grade 2 renal parenchymal disease

 treatment

Salt and fluid restriction 

Tab.nicardia10mg T.I.D

Tab .lasix 40mg B.I.D

Tab. Arkamin 100mg 

Tab. Unifer 

Capsule gel cal D3

 provisional diagnosis

Heart failure with chronic kidney disease