FINAL YEAR MBBS PRACTICAL - LONG CASE (1601006040)

 28 YEAR OLD MALE PATIENT WITH COMPLAINTS OF SHORTNESS OF BREATH , SWELLING OF LEGS AND DISTENDED ABDOMEN

APRIL 26,2021

Hello everyone, I'm a final year medical undergraduate bearing the hallticket number-1601006040. I've been allotted with this following de-identified case to present on the day of final practical exam, so I've contacted the patient and took the verbal consent to take the history and to examine the patient. 

here are the few incites which i have noticed

CHIEF COMPLAINTS:

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 PRESENTING 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

he has  history of hypertension since 1 year,no history of diabetes mellitus, asthma, epilepsy . and he had no significant complaints in the past.

FAMILY HISTORY:

he had no significant family history.

PERSONAL HISTORY:

DIET- mixed, APETITE-decreased, sleep- inadequate, bowel movements- normal, he has history of oliguria.

GENERAL EXAMINATION:-

the patient was conscious, coherent, co-operative, moderately built and 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 limb




GENERAL INSPECTION:-

JVP raised

SYSTEMIC EXAMINATION:-

Abdomen is distended , umbilicus is everted , Scar of failed AV fistula - arteriorisation of veins

No visible scars/sinuses/pulsations
No tenderness
No organomegaly
No shifting dullness/fluid thrill 
Bowel sounds heard







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
Apex beat :At left 6th intercostal space lateral to midclavicular line

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 

RESPIRATORY -

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

Inspiratory crackles present in bilateral IAA, ISA. 

Trachea position is central. 

Orthopnea is present





CNS -

Higher mental functions intact
Sensory & motor system normal
Cranial nerves intact
Reflexes present
No focal neurological deficit

Lab investigations:
Complete blood picture


HEMOGLOBIN : 8.3g/dl
RENAL FUNCTION TESTS :


Rft interpretation: urea ,creatinine and uric acid levels are elevated .
Random blood sugar


ULTRASONOGRAPHY ABDOMEN


ELECTROCARDIOGRAPHY:


Left axis deviation and left ventricular hypertrophy are interpreted on ecg.
Instruments:


MEDICATIONS:

During his hospital stay, his blood pressure has always been on the higher end and he has been going into Pulmonary edema on and off for which he been put on the following medications :

Nefidipine
clonidine hydrochloride
Sodium bicarbonate
Shelcal 500mg 
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

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