1801006187 LONG CASE
A 57 years old male resident of nakrekal 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
- 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 since -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
Bowel : regular
Bladder: decreased frequency
Addictions: he used to drink 90 ml alcohol and smoke 5 to 6 cigarettes 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.
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
There is a scar of approximately 2 to 3 cm on the right side of front of the chest.
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 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:
ckd associated with heart failure
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
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
INR: 1.4
RFT 16/03/23
Urea: 118 mg/dl
Creatinine: 5.3 mg/dl
Potassium: 3.2 mEq/l
Uric acid: 7.6 mg/dl
Calcium: 10 mg/dl
Phosphorus: 6.9 mg/dl
Sodium: 143 mEq/dl
Chloride: 98 mEq/dl
RFT : 19/3/23
Blood urea: 111
Serum creatinine: 6.7
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
ABG : 19/3/23
Ph 7.46
PCo2: 31.5mm Hg
PO2 :65.3 mn Hg
Hco3: 22.5 mol/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
Tab. Nicardia retard 10 mg/RT/BD
Tab. Metoprolol 12.5 mg/RT/OD
Tab. Nodosis 500 mg/RT/BD
regular monitoring of vitals
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