MEDICAL CASES
A 29 yrs old male AC technician by occupation hailing from Nalgonda came to the hospital with CHIEF COMPLAINTS OF:
1. Fever which is on and offsince 2 yrs
2.Shortness of breath
3. B/Lpedal edema
4 .Abdominal distension and
5.Decreased urine output since 1 year.
History of presenting illness
Patient was apparently asymptomatic 2 years back then he developed fever and generalized body pains. Fever was high grade and was associated with chills and rigor. For this he had visited local RMP where he was prescribed with some medication. With that medications fever subsided.
After few months again he developed fever and body pain for which he visited a hospital in Nalgonda. There he was prescribed with pain killers which he used for 6 months (daily).
In spite of using medications, he used to develop on and off fever. He also developed pitting type of pedal edema (extending up to knee). He visited NIMS hospital where he was diagnosed with hypertension and renal failure. He was prescribed with some medication.
Two months after visiting NIMS, he again had increased pedal edema along with decreased urine output, abdominal distension and shortness of breath.
Pedal edema- pitting type, extending up to knee
Decreased urine output- Passes urine once daily
Shortness of breath- Grade 3
For this he was advised to have dialysis. From then onwards he is under Maintenance hemodialysis
No history of palpitations
No history of chest tightness/chest pain
No history of cough
No history of yellowish discoloration of sclera
No history of burning micturition and fever.
Past history
He was diagnosed with hypertension one year back.
No history of diabetes mellitus, bronchial asthma and tuberculosis.
Family History
No history of similar complaints in family.
No history of diabetes mellitus, bronchial asthma and tuberculosis.
Personal History
Diet: Mixed
Appetite: Decreased
Sleep: Inadequate
Bowel Movements: Regular
Bladder: Decreased urine output
No known allergies
No addictions
General Examination
Patient is conscious, coherent and cooperative. Oriented to time, place, person, Moderately built and moderately nourished.
Vitals:
Temperature: Afebrile
Pulse rate: 80bpm regular, normal in volume and character. There is no radio-radial or radio-femoral delay.
Respiratory rate: 18 cycles/min
Blood pressure: 130/80 mm Hg in left arm in supine position
Pallor: Present
Icterus: Absent
Clubbing: Absent
Koilonychia: Not present
Lymphadenopathy: Absent
Edema: Present
CVS Examination
Inspection
- Chest wall appear symmetrical
- JVP - elevated
- Carotid pulsations: Bilaterally visible
- Trachea appears to be in midline
- Visible Apex beat
- Scars present
- No sinuses, engorged
- Trachea midline
- No carotid thrill
- Palpable P2
- Apex beat: 6th intercostal space lateral to midclavicular line
- No epigastric pulsations
- No tenderness
- S1 heard
- S2 heard; Loud P2
- Trachea appears to be central
- Elliptical and bilaterally symmetrical chest
- Trachea is central in position
- Both sides move equally with respiration
- No tenderness
- Resonant note heard in all areas
- Normal vesicular breath sounds heard
- Bilateral air entry is present
- Fine crepitations are heard in Right infra axillary and infra scapular area
- Abdomen is distended
- Umbilicus is everted
- No scar, sinuses, visible pulsations
- No local rise of temperature
- No tenderness
- No Organomegaly
- Shifting dullness/fluid thrill is not present
- Bowel sounds heard
- Higher mental functions intact
- Sensory system - Normal
- Motor system - Normal
- Cranial nerves intact
- No focal neurological deficit
- Tab Nicardia 20mg QID
- Tab Lasix 40mg BD
- Tab Met.XL 50mg BD
- Tab Shelcal 500mg OD
- Tab Arkamine 0.2mg TID
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