1801006075 - LONG CASE
17 March, 2023
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A 48 yr old male daily wage labourer resident of xxx was brought to medicine opd with chief complaints of
Shortness of breath since 5 days.
Decreased urinary output since 5 days.
And swelling of both the lower limbs since 1 yr which is on and off.
HISTORY OF PRESENT ILLNESS-
Patient was apparently asymptomatic 1 yr back then he developed bilateral pedal edema which was (on and off since 1 yr) and was present from ankle to knee pitting type .For this he went to hospital and there he was put on conservative management and on routine examination was diagnosed with hypertension and was started on anti-hypertensive drugs(telmisartan - 40 mg OD).
On sunday night (12/03) night around 12 AM he had an episode of shortness breath ( Class 4 - NYHA) which was sudden and associated with paroxysmal nocturnal dyspnea and orthopnea
No history of any chest pain or sweating or palpitations.
There was decreased urine output ,narrow streamlined.
And no history of any burning micturition or fever.
There is no history of cough
Stay in hospital-
He has undergone dialysis 3 times since his admission
PAST HISTORY-
History of NSAIDS abuse 4 yrs back used due to diffuse chronic bone pain.
Known case of hypertension since 1 yr using ( Telmisartan 40 mg)
Not a known case of diabetes , asthma, epilepsy, tuberculosis.
No similar complaints in the past.
FAMILY HISTORY-
No significant family history.
PERSONAL HISTORY-
Daily Routine-
He wakes around 6 AM and get ready to go to work and works for around 5-6 hours and comes back home have rest, he has his regular meals at 8AM ,1 PM and 8 PM and retires for the day around 10PM.
He is no more working
Diet - Mixed
Appetite - Normal
Bowel and bladder movements- Regular but decreased micturation.
Addictions - Smoking beedi (4 beedis per day so 6 pack years) and alcohol since 25 years ocassionally.
GENERAL EXAMINAT-
Consent was taken.
Patient was examined in a well lit room with adequate ventilation with a attendant present.
Patient is conscious coherent and cooperative well oriented to time place and person moderate built and nourished.
Pallor - Present
Icterus - Absent
Cyanosis - Absent
Clubbing - Absent
Lymphadenopathy - Absent
Edema - b/l lower limbs pitting type extending beyond ankle.
Vitals-
Temperature - 98.6 F
Pulse Rate - 74 beats per minute
Blood Pressure - 130/80 mm Hg
Respiratory Rate - 16 cycles per minute
Spo2 - 95%
CLINICAL PICTURES-
SYSTEMIC EXAMINATION-
CVS -
Inspection-
No rise in JVP
No precordial bulge
No visible pulsations
No chest wall defects
Palpation-
Apical impulse - Diffuse in anterior axillary line at 6th intercostal space
No parasternal heaves and thrills
Auscultation-
S1 and S2 heard
RESPIRATORY SYSTEM-
Inspection-
Trachea is in midline
Presence of an healing crusted ulcer in right hemithorax medial to right nipple.
No other scars and sinuses.
Shape is elliptical
Chest is bilateral symmetrical
Bilateral air entry present
No chest and spinal deformities
Palpation-
Trachea is in midline
Symmetrical chest expansion
Chest circumference- 34 inches
No tenderness over chest
Percussion-
Left. Right
Supraclavicular. R. R
Infraclavicular. R. R
Mammary. R. R
Inframammary. R. R
Axillary. R. R
Infraaxillary. R. R
Suprascapular. R. R
Infrascapular. R. R
Inter scapular. R. R
(R - resonanat)
Auscultation-
Lt. Rt
Supraclavicualr. Nvbs. Nvbs
Infraclavicular. Nvbs. Nvbs
Mammary. Nvbs. Nvbs
Inframammary. Wheeze. Nvbs
Axillary. Nvbs. Nvbs
Infraaxillary Wheeze. Nvbs
Suprascapular. Nvbs. Nvbs
Infrascapular. Nvbs. Nvbs
Interscapular. Nvbs. Nvbs
(Nvbs - non vesicualr breath sounds)
Abdominal examination-
Inspection-
Shape of abdomen is scaphoid
Umbilicus inverted
No visble pulsations peristalsis or dilated veins
Free hernial orifces
Palpation -
No local rise in temperature
No tenderness present
No palpable mass
Auscultation-
Bowel sounds heard
Central nervous system examination-
Speech normal
Intact higher mental functions
Cranial nerve examination - N
Motor examination -
Normal tone
Power 5/5 in both upper and lower limbs
Intact reflxes
Sensory examination -
Normal
Provisional diagnosis-
Heart failure with hypertension
Chronic kidney disease.
Investigations-
Hemogram -
16/03 -
Hemoglobin - 7.7 gm/dl (13-17 gm/dl)
Total count - 14,100 cells/cumm(4000-10000 cells/cumm)
Lymphocytes - 16% (20-40%)
PCV - 23.1 vol% (40-50 vol%)
SMEAR :
RBC - Normocytic normochromic
WBC - increased count
Platelets - adequate
CUE-
Serum creatinine - 4.0 mg/dl (0.9 -1.3 mg/dl)
Blood urea - 95mg/dl (12-42 mg/dl)
E Gfr - 18 ( >65)
ABG :
PH 7.43 (7.35-7.45)
Pco2 - 31.6 mmHg (35-45 mmhg)
Po2 - 64.0 mmHg(85-95 mmhg)
HCO3 - 21.1 mmol/l
Urine examination :
albumin ++
sugar nil
pus cells 2-3
epithelial cells 2-3
Red blood cells 4-5
Random blood sugar - 124 mg/dl
ECG-
X-RAY -
13/03-
2 D echo -
Final Diagnosis -
Heart failure secondary to chronic kidney disease (due to NSAIDS abuse)
Treatment -
Ryle’s feed : 100 ml milk with 2 scoops protein powder 4th hourly and 100 ml water 6th hourly.
Inj. Thiamine 100mg in 50 ml NS TID
Inj. Piptaz 2.25g IV TID
Inj. LASIX 40mg IV BD
Inj. Erythropoietin 4000IU SC Once weekly
Inj. PAN 40 mg IV OD
Tab. Nicardia Retard 10mg RT BD
Tab. Metoprolol 12.5mg RT OD
Tab. NODOSIS 500 mg RT BD
Tab. Orofer RT OD
Cap. BIO D3 RT OD
Hemodialysis
Nebulisation with Duolin 8th hourly and Budecort 12th hourly
Intermittent CPAP
Allow sips of oral fluid
Monitor vitals.
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