LONG CASE
A 65 year old male patient came with shortness of breath, distension of abdomen and pedal edema
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CHIEF COMPLAINT
A 65 year old male patient mason by occupation came to opd with complaint of SOB, distension of abdomen,and pedal edema since 1 week
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic one year back
March 2022
Patient was taken to private hospital with complaint of shortness of breath,pedal edema and distension of abdomen,fever and was alcoholic
Was diagnosed with renal failure and heart failure
June 2,2022
Patient again developed similar complaints and was diagnosed with anemia
Hb 5 and 20 prbc transfusion was done
1 week back on 15-1-2023
Patient complained of shortness of breath which was insidious in onset progressed from Garde 2to grade 3, orthopnea ( )
Chest pain radiating to arms was relieved on medication
Decreased urine output
Pedal edema was present since 3months which is of pitting type and increased during standing
HISTORY OF PAST ILLNESS
No h/o Tb ,epilepsy,Asthma
Has h/o DB
HTN -7years back
FAMILY HISTORY
No significant complaints in family history
PERSONAL HISTORY:-
Married
Appetite- Normal
Diet - Mixed
Bowel and bladder- Regular
No known allergies
Habits- alcohol (stopped one year back)
GENERAL EXAMINATION
pallor-yes
Pedal edema-yes
No clubbing of fingers ,cyanosis,icterus,lymphadenopathy
VITALS
Temperature-Afebrile
Pulse rate -78bpm
Bp-110/90mm of Hg
spo2-98%
SYSTEMIC EXAMINATION:
CVS
S1 &S2 heard
No thrills
No cardiac murmurs
RESPIRATORY SYSTEM
INSPECTION
Size and shape -bilaterally symmetrical
Position of trachea-central
Apical impulse-not seen
Chest expansion-symmetrical
PALPATION:
Trachea- midline
Chest movements- symmetrical
No intercoastal widening
Measurements of chest expansion
Right hemithorax-28cm
Left hemithorax-27cm
PERCUSSION
No tenderness over chest wall
No added sounds
No pleural rub
Right Left
Supraclavicular R R
Infraavicular R R
Mammary R. R
Infra mammary Dull R
Axillary R R
Infra axillary R R
Suprascapular R R
Interscapular R R
Infrascapular Dull R
AUSCULTATION
Normal vesicular breath sounds heard
Dyspnoea,wheeze - present
Right Left
Supraclavicular NVBS NVBS
Infraclavicular NVBS NVBS
Mammary NVBS NVBS
Axillary NVBS NVBS
Infra Axillary NVBS NVBS
Suprascapular NVBS NVBS
Interscapular NVBS NVBS
Infrascapular NVBS NVBS
ABDOMEN
INSPECTION
Shape of abdomen: distended
Surface of abdomen has no scars ,dilated veins , visible peristalsis
PALPATION
Liver and spleen not palpable
PERCUSSION
Resonance sound is heard
AUSCULTATION
Bowel sounds are heard
CNS
Patient is conscious
Speech normal
No neck stiffness
Motor and sensory system- Normal
PROVISIONAL DIAGNOSIS
CKD secondary to diabetic nephropathy
Diabetes mellitus
Hypertension
INVESTIGATIONS
TREATMENT
Tab lasix 40mg
Tab Nodosis 500mg
Tab Orofer
Tab Nicardia 10mg
Cap Bio D3
Tab carvidilol
Tab shelcal
Salt fluid restriction
