final long case
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A 78 years male patient occupation by farmer came to opd with chief complaints of
Bilateral pedal edema and shortness of breath, PND since 2 months
HISTORY OF PRESENT ILLNESS :
He was asymptomatic 1year back then he noticed decreased urine output , developed edema (upto knees) and shortness of breath (grade 3 NYHA classification) for which he went to a local hospital and diagnosed with renal failure and started on conservative management. Then from 2 months back he again developed bilateral pedal edema which is of pitting type and shortness of breath.
HISTORY OF PAST ILLNESS :
Hypertension since 15 years
Diabetes since 6 years
History of renal failure 1 year back
History of dialysis 1 year back
No other surgeries.
No history of tuberculosis, epilepsy and asthma
DRUG HISTORY :
Patient was on medication for diabetes ( insulin) and hypertension (nicardia ,metoprolol succinate)
No allergies to known drugs
PERSONAL HISTORY :
Married
Mixed diet
Normal appetite
Bowel and bladder movements regular
Micturition normal
Sleep inadequate
No Addictions
FAMILY HISTORY :
NO significant family history
GENERAL EXAMINATION :
Patient was examined after taking consent.
Patient was conscious , coherent, coperative and well oriented to time place and person.
pallor
No icterus
No cynosis
No lymphadenopathy
No clubbing
Bilateral pedal edema present
VITALS :
Temperature-:afebrile
Pulse rate -:86/min
Resp rate -:18/min
Bp -:110/80 mmHg
SYSTEMIC EXAMINATION :
RESPIRATORY SYSTEM-:
On inspection:
Chest is bilaterally symmetrical
Trachea – central
No Drooping of shoulders,
No suprasternal and supraclavicular notching is present
No Sinuses, scars, dilated veins, nodules
Movement with respiration bilaterally symmetrical
On palpation:
No local rise of temperature
No tenderness
All the inspectory findings are confirmed.
Trachea - central
No Intercostal widening/crowding of ribs
Chest movement symmetrical
Measurement of Chest expansion -
Whole thorax expansion :36 inspiration
35 expiration
Hemi thorax expansion :17
Vocal Fremitus: normal
On percussion:
Resonant sounds are heard
Dull notes from 5th intercoastal area
On auscultation:
Normal Vesicular Breath sounds
No Added sounds
Vocal Resonance vibrations are heard
CVS-:
No raised jvp
On inspection:
Bilaterally symmetrical chest
No visible pulsations
No scars /sinuses
No engorged veins
On palpation :
Apex beat :at 5th intercoastal space
No thrills
On Auscultation :
S1 &S2 are heard
No murmurs are heard
ABDOMEN:
On inspection:
shape : obese
Flanks : full
Umbilicus: central and inverted
No engorged veins
No visible pulsations
No scars
No Hernial Orifices
On palpation :
No local rise of temperature
No tenderness
No palpable masses
No organomegaly
On percussion:
No ascites
No fluid thrill
No shifting dullness
Auscultation :
Bowel sounds present
No bruits
CNS-:
Consious, coherent ,cooperative
Speech normal
No neck stiffness
No meningeal signs
Motor system : normal
Sensory system: normal
Able to percieve-:pain , temp.
Cranial nerves : intact
No cerebellar signs
PROVISIONAL DIAGNOSIS :
Heart failure
CKD on MHD
INVESTIGATIONS:
Blood grouping and Rh type : 0+ve
Anti HCV antibodies : negative
HBsAg(Rapid &ELISA) : negative
HIV1/2(rapid&ELISA) : non reactive
Complete blood picture
Complete urine examination
ABG
USG
Chest xray
ECG
Liver function tests
Renal function tests
FINAL DIAGNOSIS:-
CKD on MHD
Treatment:
Treatment:Inj lasix 40mg iv/bd
Inj.Erythropoietin 4000IU sc once weekly
Inj.pan 40mg iv/od
Inj.optineuron 1ampule in 100ml NS IVSTAT
Tab.nodosis 500mg po/bd
Tab orofer -xt PO/BD
Tab Shelcal 500mg PO/BD
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