160106068- short case

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 This is an online e logbook to discuss our patients de identified health data shared after his guardian informed consent .


A 45 yr old male patient resident of Nalgonda, labourer by occupation came with chief complaints : 

. Pedal edema since 10 days

. Shortness of breath since 10 days

. Decreased urine output since 5 days

.  Fever since  5 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 10 days ago .then  he developed ,

- bilateral pedal edema  since 10 days which is insidious in onset , gradually progressive, which is pitting type

- shortness of breath since 10 days = insidious in onset , non progressive, aggrevated on walking, excercise, relieved on sitting.

- fever since 5 days insidious in onset , intermittent not associated with  chills and rigor, head ache, vomiting fever not associated with chills & rigors.

- history burning micturition, oliguria since 5 days

- no history of sweating, chest pain  ,hematuria

PAST HISTORY:

 he had  kidney issues  6 months back, for that he took medication. He had TB in the past 1 yr , that is cured.

no history of diabetes mellitus, hypertension, asthma , epilepsy

No surgical history

PERSONAL HISTORY:

Mixed diet, decreased appetite,bowel movements are regular, normal there is history of burning micturition and oliguria, smoking since  25 yrs 2 to 5 beedis per day alcoholic since 10 years once weekly.

FAMILY HISTORY : not significant

GENERAL EXAMINATION:

patient is concious, co operative, moderately built , moderately nourished.  Pallor  present,No icterus, no cyanosis, no clubbing, no lymphadenopathy

- pedal edema present

Vitals  :

Pulse rate- 80 bpm

BP- 130/80 mmHg

RR -20 cpm

Afebrile

SYSTEMIC EXAMINATION :

Respiratory system : 

Inspection - shape & symmetry of chest normalNo visible scars, no sinuses, no engorged veins  

Palpation:   

no lacal rise of temperature, no tenderness

trachea  is central  

apex beat  is felt at 5 th intercostal space lateral to mid clavicular line 

Decreased chest expansion

vocal fremitus decreased at infraclavicular, intramammary area

 Percussion: dull note seen on    infrascapular area on both sides

Auscultation :

- bilateral air entry present

- normal vesicular breath sounds heard

- fine crepitations heard on bilateral infra axillary & infraspinatus areas

CVS :

S1 & S2 heard , no murmurs, no thrills

ABDOMINAL EXAMINATION :

 Scaphoid shape

No tenderness

No organomegaly

No ascites

Bowel sounds present

CNS : pt concious alert, normal gait, no signs of meningeal irritation, cranial nerves intact,


INVESTIGATION S :

. CBP , CUE , RFT, LFT, Blood sugar ,ESR , serum potassium ,  blood culture , chest X ray , 

 Treatment :

Salt and fluid restriction

- injection IV lasix 40 mg bid

- Tab NODOSIS 500 mg

- Tab SHELCAL 500 mg od

- BuDicort

Provisional diagnosis :

Acute on chronic renal failure with bilateral pleural effusion







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