1801006158 - LONG CASE

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box"

48 Yr old male , mason by occupation  and resident of Nakrekal, came to OPD with cheif complaints of - Shortness of breath since 1 week 

                         - Decreased urine output since 1 week

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 1week back .Then he developed shortness of breath during climbing stares and even walking at normal pace ( grade 2) , which gradually prdiet ogressed even at rest and last one week ( grade 4) .   It was aggravated by doing work and by lying horizontally on bed and relieved by taking rest in reclined position .  

There is history of gradual decreased urine output since 1 week which is not associated with increased frequency, urgency or incontinence

No H/O fever, chronic cough, weight loss, hemoptysis, sputum

No H/O chest pain, sweating, palpitations, syncope 

No H/O burning micturition, difficulty in micturition

Past history

  • No similar complaints in past
  • History of pedal edema on and off since 1 year, present upto level of ankle
  • He is a known case of hypertension since 1 year and he takes telmesartan 40mg every day morning after breakfast 
  • No H/O diabetes, asthma, tuberculosis, epilepsy. 
PERSONAL  HISTORY 

Diet - mixed  

Appetite- normal 

Sleep adequate 

Bowl and bladder movements - regular

Addiction -  drank 90ml alcohol regularly since 30 to 35 years 

Smoke bd daily 6/7 since last 30 to 35 years 

Now he is an occasional drinker and smoker 

Family history- 

Not similar complaints 

Treatment  history 

Since last 4 years he is taking analgesics for knee pains. He took them occasionally in the beginning , but since last 2 years he took them daily or on alternate days.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 -ve

Generalised edema -ve










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: 

Upper respiratory tract: no halitosis, oral thrush, tonsillitis, deviated nasal septum, turbinate hypertrophy, nasal polyp

Lower respiratory tract:

chest is bilaterally symmetrical

Trachea is in midline

Moving symmetrically with inspiration and expiration

No drooping of shoulders, supraclavicular and infraclavicular hollowing, intercostal fullness, retractions, indrawings, crowding of ribs

There is a scar of approximately 2 to 3 cm on the right side of front of the chest. Similarly — Lesions are present on the back of the chest

Palpation:

Trachea is central on palpation

No intercostal widening/crowding, subcutaneous emphysema, intercostal tenderness

Apical impulse is felt in 6th intercostal space lateral to mid clavicular line

Chest movements are bilaterally symmetrical

Chest measurements:

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

No local rise in temperature and no tenderness

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 heardCrepts are heard in right and left infra axillary and infrascapular areas

Wheeze is audible in right and left inframammary area

CVS

Inspection: 

Chest wall is normal in shape and is bilaterally symmetrical

Apex beat appears to be present at 6th intercostal space lateral to mid clavicular line

No precordial bulge, kyphoscoliosis

No visible veins and sinuses

Palpation: 

Apical impulse is felt at 6th intercostal space lateral to mid clavicular line

All peripheral pulses are felt and compared with opposite side

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 local rise of temperature

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: heart failure with hypertension

Investigations 

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

ABG 

Ph: 7.43

PCO2: 31.6 mm Hg

PO2: 64 mmHg

HCO3: 21.1 mol/L

LFT: 

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

RFT 

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

Serology: negative for HIV & HbsAg

Ultrasound

Right kidney: 7.5*4.5 cm

Left kidney: 7.5*4.2 cm

Both kidneys: decreased size and increased echogenicity 

   Corticomedullary differentiation is lost




Diagnosis- 

Left heart failure with chronic kidney failure..

Treatment 

 Inj. Thiamine 100mg IV/TID

 Inj. Lasix 40 mg/IV/BD

 Inj. Erythropoietin 4000 IU/SC/ once weekly

 Inj, PAN 40mg/IV/OD

Tab. Nicardia retard 10 mg/RT/BD

Tab. Metoprolol 12.5 mg/RT/OD 

Tab. Nodosis 500 mg/RT/BD

Nebulisation with duolin 8th hrly & budecort 12th hrly 

Intermittent CPAP

regular monitoring of vitals












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