Roll.No.1801006170. LONG CASE

A 57 years old male resident of palem  who used to work as a construction worker came to opd 8 days back with chief complaints of  shortness of breath,pedal edema,decreased urine output and abdominal distension.

HISTORY OF PRESENTING ILLNESSES: 

patience was apparently asymptomatic 1yr ago then he developed shortness of breath after walking and climbing of stairs and relieved on taking rest 

He also developed pedal edema 1yr ago 

They refered a local hospital in suryapet where he was diagnosed with hypertension and is on medication since then 

He was also diagnosed with kidney disease and adviced of dialysis for which they declined and was on medications for 6 months 

8 days back he developed shortness of breath at rest which relieved on reclined position and bilateral pedal edema he also observed decreased urine output and abdominal distension 

NEGATIVE HISTORY :

no history of fever, weight loss

No history of chest pain, palpitations 

No history of burning micturition and difficulty in micturition

PAST HISTORY : 

History of hypertension since 1yr and is medication 

No H/O diabetes, asthma, tuberculosis, epilepsy

PERSONAL HISTORY

diet: mixed 

Appetite: normal

Sleep: adequate

Urine output decreased

Addictions: he used to drink 90 ml alcohol and smoke 5 to 6 cigarette regularly since last 30 to 35 years. Since last 1 year he only drink and smoke occationally

FAMILY HISTORY

No similar complaints in family 

TREATMENT HISTORY

Since last 4 years he is taking analgesics for knee pains. He took them occasionally in the beginning , but since last 2 years he took them daily or on alternate days.

Since last 1 year he is taking telmesartan 40 mg every day morning for hypertension

GENERAL EXAMINATION:

pallor -ve



Icterus -ve 




Clubbing -ve

Cyanosis -ve 



Lymphadenopathy absent 

Generalised edema absent 





VITALS:

Temperature: afebrile

Pulse rate: 90 bpm

Respiratory rate: 18 cpm

Blood pressure: 130/80 mm hg 

Grbs : 124 mg/dl

SpO2 : 92 %

SYSTEMIC EXAMINATION:

Respiratory system

Inspection: normal chest movement

                      Symmetrical 

                      Trachea central 

                      No drooping of shoulders

                      No retractions

Palpation:no local rise of temperature

                   Trachea is central on palpation

                   Apical impulse is felt in 6th intercostal space lateral to mid clavicular line

Chest movements are bilaterly symmettical

Tactile vocal fremitus Right Left

Supraclavicular Resonant Resonant

Infraclavicular   Resonant Resonant

Mammary.          Resonant Resonant

Inframammary Resonant Resonant

Axillary.              Resonant Resonant

Infraaxillary        Resonant Resonant

Suprascapular   Resonant Resonant

Infrascapular      Resonant Resonant

Interscapular      Resonant Resonant 

Percussion               Right      Left

Supraclavicular Resonant    Resonant

Infraclavicular   Resonant    Resonant

Mammary          Resonant    Resonant

Inframammary    Resonant.  Resonant

Axillary.              Resonant     Resonant

Infraaxillary         Resonant    Resonant

Suprascapular.     Resonant   Resonant

Infrascapular       Resonant    Resonant

Interscapular.       Resonant  Resonant

No percussion tenderness

Auscultation:

Normal vesicular breath sounds are heard

Wheeze is audible in right and left inframammary area

CVS

Inspection: 

Chest wall is normal in shape and is bilaterally symmetrical

No precordial bulge, kyphoscoliosis

No visible veins and sinuses

Palpation: 

Apical impulse is felt at 6th intercostal space lateral to mid clavicular line

No parasternal heaves, precordial thrills

Percussion:

Left heart border is shifted laterally, and right heart border is present retrosternally

Auscultation:

Mitral, tricuspid, pulmonary, aortic and Erb’s area auscultated

S1 S2 are heard, no abnormal heart sounds.

CNS

Higher mental functions are intact

Cranial nerve functions are intact on right and left sides

Motor system: bulk and tone are normal

Power is 4/5 in all 4 limbs

Deep tendon reflexes are present and normal

Superficial reflexes are present and normal

No involuntary movements

No signs of cerebellum dysfunction

No neck stiffness, kernigs and Brudzinski’s signs are negative

ABDOMINAL EXAMINATION

Inspection:

Abdomen is flat and flanks are free

Umbilicus is inverted

No visible scars, sinuses, dilated veins, visible pulsation

Hernial orifices are normal

Palpation:

No tenderness and enlargement of Liver, spleen, kidney 

Percussion:

No fluid thrill

Liver span is normal, no spleenomegaly

Auscultation:

Bowel sounds are heard 

PROVISIONAL DIAGNOSIS

Heart failure with CKD 

INVESTIGATIONS

16/03/23

Hemoglobin: 8.1Gm/dl

Total count: 12680 cells/Cumm

Neutrophils: 74%

Lymphocytes: 12%

Eosinophils: 00%

Monocytes: 14%

Basophils: 00%

PCV: 25 vol%

MCV: 89.6fl

MCH: 23.0pg

MCHC: 32.4%

RBC count: 2.79 million/cumm(4.5-5million /cumm)

Platelet count: 2.16 lakhs/cumm

Smear: normocytic normochromic, no hemoparasites

19/3/23

Hemogram 

Hb 8.3 gm/dl

Total leukocytes : 15600 cells /cumm

RBC: 2.8 million / cumm

Platelets: 2.2 lakhs / cumm

Prothrombine time : 19secs

RFT :16/03/23

Urea: 118 mg/dl(15-40mg/dl)

Creatinine: 5.3 mg/dl(0.8-1.3mg/dl)

Potassium: 3.2 mEq/l

Uric acid: 7.6 mg/dl(3.5-7.5mg/dl)

Calcium: 10 mg/dl(8.5-10.5mg/dl)

Phosphorus: 6.9 mg/dl(2.8-4.5mg/dl)

Sodium: 143 mEq/dl

Chloride: 98 mEq/dl

RFT : 19/3/23

Blood urea: 111(15-40mg/dl)

Serum creatinine: 6.7(0.8-1.3mg/dl)

Sodium :142

Potassium: 3.2

Chlorine :96

LFT: 13/03/23

Total bilirubin: 0.77 mg/dl

Direct bilirubin: 0.20 mg/dl

AST: 24 IU/L

ALT: 11 IU/L

ALP: 312 IU/L

Total protein: 6.2 Gm/dl

Albumin: 3.04 Gm/dl

A/G ratio: 0.96

ABG :17/03/23

Ph: 7.43

PCO2: 31.6 mm Hg

PO2: 64 mmHg

HCO3: 21.1 mol/L(21-29meq/dl)

ABG : 19/3/23

Ph 7.46

PCo2: 31.5mm Hg(35-45mmhg)

Hco3: 22.5 mol/L(21-29meq/l)

O2 saturation : 90.4

Serology: negative for HIV & HbsAg

X RAY


Ultrasound

Right kidney: 7.5*4.5 cm


Left kidney: 7.5*4.2 cm


Both kidneys: decreased size and increased echogenicity.


DIAGNOSIS:

Chronic kidney disease

Heart failure 

TREATMENT:

 Inj. Thiamine 100mg IV/TID

 Inj. Lasix 40 mg/IV/BD

 Inj. Erythropoietin 4000 IU/SC/ once weekly

 Inj, PAN 40mg/IV/OD

Tab. Nicardia retard 10 mg/RT/BD

Tab. Metoprolol 12.5 mg/RT/OD 

Tab. Nodosis 500 mg/RT/BD

regular monitoring of vitals

Comments

Post a Comment

Popular posts from this blog

A 70 years old female referred from surgery to GM with the shortness of breath and b/l pedal edema

Image
Patient was apparently asymptomatic 2weeks back then she developed right leg swelling associated with wound on  the right ankle and right leg anterior region. Swelling extended from the right foot to the mid part of shin.debridement of infection was done four days back.she had h/o of atrial fibrillation before surgery which is controlled. After surgery due to stress  induced  factor atrial fibrillation which-eventually  lead to left heart failure and then right heart failure she developed shortness of breath and pedal edema. No h/o of fever, vomiting Past history: Not known Case of HTN,DM, asthma, qq1 Personal h/o Diet: mixed Bowel and bladder! Regular. Family ho:- No significant family history. GENERAL EXAMINATION:   pt is cc and non cooperative, moderately built and moderately nourished, well oriented with place and time, No pallor, no icterus, no cyanosis, no clubbing, no lymphadenopathy. Vitals: Pulse rate- 123 Bp - 110/80 Rr- 22 Temp- 98.4F Oxygen saturation 96% Systemic examinati
Read more

53 Year old female patient

Image
A 53 year old female patient came to opd with chief complaint shortness    of breath since 3days .decreased urine output.    History of present illness:patient was apparently asymptomatic 10 months back.Then she developed SOB.She is brought to hospital found PH,raised creatine ,urea levels. which is Diagnosed as kidney failure.Then she underwent dialysis for every 2-3 times a week.she had two times blood transfusion  .Three days back she developed shortness of breath and decreased urinary output. PAST HISTORY: There was a history of HTN,NO H/O DM,ASTHMA ,TB,EPILEPSY. Personal history: Appetite normal Diet:mixed Bowel movements:regular BLADDER:Decrease urinary output No allergies No addiction Family history: No significant family history General examination Patient was consious,coherent,and cooperative,well oriented with time and place. Bp:150/90 Temperature:98F Pulse:86 Pallor:present Icterus:absent Clubbing:absent Cyanosis:absent Lymphadenopathy:absent Oedema:bilateral pedal oedema wh
Read more

45 years old male with seizures one week back

Image
CHIEF COMPLAINTS  an episode of seizures 1 week back and he had bleeding from mouth    HISTORY  OF PRESENTING ILLNESS: Patient was apparently asymptomatic 20 years ago after which he started consuming alcohol ,initially he started consuming toddy when he was young then he started consuming alcohol with his friends at his work 3-6 units weekly once on Sunday.This continued for 7years back.He started consuming alcohol excess due to family problems.he had 3 years  back  ah/o of 3episodes of seizures each episode precedes consumption of alcohol is present.he decided that alcohol might be the reason and went to a local doctor who told the same reason for which he decided to stop consuming alcohol which he did.he was abstinent for one year.Again he started consuming alcohol duo to family problems. One week back then he developed an episode seizures while he was doing his work on monday .Then he went to the RMP for the treatment he had given a tablet for it and the seizures subsid
Read more