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 limbs
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
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
