Long case(1601006021)
29 year old male unmarried who is a daily wage labourer resident of Nalgonda, came to hospital with chief complaints of on & off fever since 2 yrs , shortness of breath , b/l pedal edema , abdominal distension and decreased urine output since 1 year
History of present illness:
Patient was apparently asymptomatic 2years ago and then one day he developed
fever (high grade , continuous , associated with chills & rigors) and generalized body aches for which he went to a local RMP and he prescribed some tablets.
Fever subsided temporarily and he used to get fever at night.
So he went to a local hospital in nalgonda where they prescribed him some pain killers for his body pains & fever which he continued to take daily for nearly 5-6 months (2-3 tablets/day).
Inspite of that he had on & off fever & pedal edema(b/l pitting type extending upto knees) for which he went to NIMS where he was diagnosed as hypertensive & renal failure.
2 months later he had increased pedal edema associated with decreased urine output , abdominal distension and SOB grade 2-3 for which dialysis was advised & he came to our hospital.
From then he was on maintainence hemodialysis.
From past 5-6 months SOB increased gradually to grade-4 with associated orthopnea & PND
No h/o chest pain/palpitations/chest tightness
No h/o fever/cough at present
No other complaints
PAST HISTORY:
Hypertension since 1 year
No h/o DM/ asthma/epilepsy/CAD
PERSONAL HISTORY:
Mixed diet
Disturbed sleep
Decreased appetite
Normal bowel & bladder habits
No addictions
Family history:
No relevant family history seen .
General examination:
Patient is conscious , coherent and cooperative.
Oriented to time, place and person.
He is moderately built and moderately nourished.
Temperature: afebrile
Blood pressure: 130/90mm Hg
Resp rate:12 cycles per min
Pulse rate : 82bpm
Pallor : Present
icterus : absent
Clubbing: not present
Koilonychia: not present
Lymphedenopathy: not present
Edema : present in limbs
GENERAL INSPECTION:
JVP raised
Scars are present
Scar of failed AV fistula - arteriorisation of veins
So they planed dialysis on femoral vein
CVS:
INSPECTION:
Examination of neck
Carotids : bilaterally visible
JVP : elevated
Trachea in the midline
Visible apex beat
Palpation
Trachea midline
No carotid thrill
thrill present at tricuspid area
Palpable P2
HEMOGLOBIN : 8.3g/dl
Rft interpretation: urea ,creatinine and uric acid levels are elevated .
clonidine hydrochloride
Sodium bicarbonate
Shelcal 500mg
Apex beat :At left 6th intercostal space lateral to midclavicular line
Palpation and locating apex beat
No suprasternal ,epigastric and Interscapular impulses.
PERCUSSION:
Rt heart border corresponding to rt sternal border
Left Heart border corresponding to line joining apex in left 6th intercostal space
Rt & lt 2nd intercostal spaces are resonant
AUSCULTATION:
S1 S2 heard
P2 loud
High pitched grade 4 Pansystolic murmur heard on mitral and tricuspid area
Abdomen examination:
Distended abdomen
Umbilicus everted
No visible scars/sinuses/pulsations
No tenderness
No organomegaly
No shifting dullness/fluid thrill
Bowel sounds heard
RESPIRATORY SYSTEM EXAMINATION:
Elliptical & bilaterally symmetrical chest
Both sides moving equally with respiration
Resonant note heard in all areas
Bilateral air entry present
Normal vesicular breath sounds
Fine crepts heard in right infra axillary & infra scapular areas
CENTRAL NERVOUS SYSTEM EXAMINATION:
Higher mental functions intact
Sensory & motor system normal
Cranial nerves intact
Reflexes present
No focal neurological deficit
Lab investigations:
Complete blood picture
RENAL FUNCTION TESTS :
Random blood sugar
Chest Xray:
ULTRASONOGRAPHY ABDOMEN
ELECTROCARDIOGRAPHY:
Left axis deviation and left ventricular hypertrophy are interpreted on ecg.
Instruments:
Medications :
Nefidipine
Provisional diagnosis :
Based on the above findings decreased urine output ,mild ascites,shortness of breath ,my diagnosis is something related to kidney and heart pathology .
On lab investigations my diagnosis is
Chronic kidney disease with heart failure.
