Long case - General Medicine

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                        LONG CASE

 45 year old male, resident of  ramanapet, farmer by occupation, came to the Opd, with chief complaints of 

shortness of breath since one year.

Bilateral pedal edema since three months.

 HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic one year back then he developed, shortness of breath, which was insidious in onset gradually progressive from grade two to grade four, aggravated on lying down and on exertion and relieved by medications.

The patient also complains of pedal edema since 3 months, insidious in onset, gradually progressive from involving the ankle to involving the whole limbs, pitting type,  aggravated by walking , slight in the morning and more by the end of the day which relieved on elevating the legs. 

Patient also gives a history of decreased urine output since 1 month, insidious onset,  gradually progressive.

There's history of weight loss.

No h/o paroxysomal nocturnal dyspnea.

No history of cough and expectoration, chest pain, no history of palpitations and syncope .No history of fever, sore throat, joint pains. No hemoptysis, hematemesis, no history of Jaundice, no history of burning micturition.

PAST HISTORY:

He had a road traffic accident 3 years back, had a surgery on right leg and was on medications for one year (analgesics).

He is a known case of hypertension since 2 years, diagnosed when he went to a camp- was using nicardia 20 MG thrice daily and stop taking tablets since one year.

The patient is on dialysis since 10 months.

He is not a known case of diabetes, TB asthma, epilepsy.

PERSONAL HISTORY:

He has a mixed diet.

Appetite- normal

Sleep- disturbed 

Bladder- irregular

 Bowel movements- regular

 Addictions- chronic alcoholic for 20 years stopped drinking since last three years.

FAMILY HISTORY:

There is no significant family history.

DRUG HISTORY:

The patient used analgesics for a year.

 Used nicardia 20 MG for Hypertension.

GENERAL EXAMINATION:

The patient is conscious, coherent, Cooperative, moderately built and nourished.

Pallor - present

There are no signs of icterus, cyanosis, koilonychia, clubbing and lymph adenopathy.

Edema- present.

JVP- raised.

A-V fistula- felt

VITALS:

PR- 82bpm,regular,normal volume

BP- 130/80mm Hg right arm, sitting position

RR- 24cpm

TEMP- afebrile.

Local examination of cardiovascular system

Trachea appears to be Central 

Shape of the chest - normal

Apical impulse visible, appears to be shifted from its normal position.

no visible scars, sinuses, dilated veins in any part of the thorax, no bony abnormalities.

Palpation:

All Inspectory findings are confirmed.

Trachea is central confirmed by 3-finger test.

Apex beat is shifted outwards and downwards, 4 to 5 cm lateral to mid clavicular line in 6th intercoastal space.

no palpable heart sounds and no palpable murmurs. 

Percussion:

Right heart border shifted 1 cm right  from the right sternal 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 sinuses, scars or visible pulsations 

hernial orifices are free.

Palpation :

no local rise in temperature 

no tenderness 

no guarding and rigidity 

no palpable masses.

Percussion:

shifting dullness- present

liver span-normal

Auscultation:

bowel sounds are heard.

Respiratory system :

bilateral air entry- present

normal vesicular breath sounds heard 

basal crepitations present in both the lung fields.

Central nervous system- normal.

INVESTIGATIONS:

CBP- 

Hemoglobin- reduced

PCV- reduced 

RBC count -reduced

CUE-

Albumin in urine

RANDOM BLOOD SUGAR-

X-RAY:

ECG-

RFT:

 Serum urea and creatinine- raised.

LFT:

SERUM IRON:

USG ABDONEN:

Grade-II renal parenchymal disease

PROVISIONAL  DIAGNOSIS:

CHRONIC KIDNEY DISEASE WITH HEART FAILURE.

TREATMENT: 

Salt and fluid restriction

Tab. Nicardia 10mg T.I.D

Tab. Lasix 40mg B.D

Tab. Arkamin 100mg

Tab. Unifer

Capsule. Gel cal D3