long case
Date of admission of the patient January 17th.
A 65 year old male patient from nagarjuna Sagar farmer by occupation came to the OPD with the chief complaint of bilateral pedal edema and shortness of breath since 1 week and is on bed rest since then.
HISTORY OF PRESENT ILLNESS.
Patient was apparently asymptomatic 10 years back then he met with an accident (fell while riding bullock cart injuring his mandible) .
Later he got diagnosed with heart failure and started using NSAIDS 5 yrs back.
History of single episode of tonic seizure at night 5yrs back and visited a physician near his place and got prescribed with phenytoin 100mg bd .
Patient had bilateral pedal edema pitting type, extending till knees, SOB( NYHA grade 2 and 3,MMRC grade 2 and 3)which was present with farm work started insidiously, progressing over time,exertional ,non seasonal,reached the present state (exertion even at rest , NYHA grade 4,MMRC grade 4), associated with increase during sleeping position and relieves on sitting or standing and he was taken to hospital in hyderabad where he got diagnosed with NSAIDS induced
nephropathy with hypertension 4 yrs back.
Patient underwent 12 heamodialysis sessions( first 6 from August 2021 and next 6 from july 2022) and later was on conservative management.
Patient complaints of sob ( NYHA grade 3, 4), orthopnea and pnd since 1 week.complaint of cough with expectoration intermittently,not associated with fever,no diurnal variations.Expectoration whitish ,not foul smelling,no plugs,no Frank blood.
No H/o palpitations, burning micturition.
History of pleural effusion.
HISTORY OF PAST ILLNESS:
known case of CKD since 5 years
Known case of hypertension since 4 yrs
No H/o DM, asthma,TB,jaundice.
No known drug allergies.
PERSONAL HISTORY
Diet : mixed
Appetite : reduced
Bowel and bladder movements : regular
Sleep : disturbed since 1 week due to orthopnea and pnd
Habits : alcoholic( occasionally 3 to 5pegs per occasion)
Tobacco smoking ( regular 10 - 12 beedies per day)
No known drug allergies
Daily routine before sob development: patient is a farmer by occupation and gets up morning early and goes to farm to do his work has lunch at 1pm and stays at farm till evening (sunset) has mixed diet everytime goes to bed at 10 pm ( mostly)
FAMILY HISTORY
No history of similar complaints in the family .
No history of sudden cardiac death in the family.
GENERAL EXAMINATION
Patient was concious, coherent cooperative,well oriented to time and place
Patient is moderately build and moderately nourished
No Pallor ,icterus,Cyanosis,Clubbing Generalized lyphadenopathy
Bilateral pedal edema - present
VITALS
Temperature - afebrile
Pulse rate - 89bpm
Respiratory rate - 22cpm
Blood pressure -140/80mmhg
Spo2 - 94%
SYSTEMIC EXAMINATION
CVS
Inspection
Chest wall is symmetrical
No deformity or bulge
No superficial engorged veins
Palpation
Apical impulse : present at 5th intercostal space
Auscultation
Regular rhythm
S1 , S2 heard ,no murmurs
Percussion:
Respiratory system
Dyspnoea - present
Wheeze - present
Inspection
Chest : symmetrical
Trachea position - central
No drooling of shoulders
No scars and sinuses over the skin
No superficial engorged veins
No supraclavicular hollowing
no use of accessory respiratory muscles
Movement with respiration is symmetrical on both sides
Palpation
Treachea position - central
Auscultation
Vesicular breath sounds
Percussion
Left lower side has a dull note
Abdomen
Inspection
Shape - distended
Umbilical position - central
Skin - no scars and sinuses
No superficial engorged veins
Palpation
No tenderness
No local raise in temperature
Liver , spleen not palpable
Auscultation
Bowel sounds - Heard
Bruit - not heard
Percussion: vesicular breath sounds
CNS
Consciousness
Speech : normal
kerning sign - negative
Memory intact
Speech:normal
Gait: normal
No signs of neck stiffness
Sensory system :normal
Motor system: normal
Oral cavity examination:
Hypodontia with resolved ridges
Teeth Mobility
Generalized calculus
No evidence of gingival hypertrophy
PROVISIONAL DIAGNOSIS
CKD with hypertension
INVESTIGATIONS
Tab. Lasix 40mg po bd
Tab. Nodosis 500mg po bd
Tab. Orofer po od
Tab .shelcal po od
Tab . Phenytoin 100mg po od
Tab .metxl 25mg po od
Tab . Isolazine po od
Cap . Bio D3 po nce weekly
Inj. EPO 4000IU once weekly
