1601006195 long case

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HTNo.1601006195

GENERAL MEDICINE LONG CASE

A 45 year old male resident of Nalgonda labourer by occupation presented  with chief complaint of : 

1.Shortness of breath since 10 days  

2.Cough since 10 days 

3.Swelling of both legs since 10 days

 

History of presenting illness 

Patient was apparently asymptomatic 10 days ago,then he developed 

1.Grade III  shortness of breath which was insidious in onset , nonprogressive,aggravated by walking, strenous work  and dressing , relieved on sitting.            

History of orthopnea                       

No history of PND.

 

2.Dry Cough  since 10days which is insidious in onset , non progressive ,no aggrevating and relieving factors

3. Grade 3  Bilateral Pedal edema  since 10 days which is insidious in onset , gradually progressive,pitting type , no aggravating and no relieving factors 

          Fever since 10 days which is insidious in onset ,with evening rise of temperature , intermittent , not associated with chills and rigors , headache , vomiting 

• History of burning micturition and oliguria since 5 days 

• There is no history of sweating , palpitations , chest pain , hematuria.

Past history 

• He was diagnosed with TUBERCULOSIS 2 years back and took  antitubercular drugs for 6 months.

• Not a known case of diabetes ,hypertension,asthma , convulsions

• Surgical history is not significant.      

Family history 

  No significant family history 

Personal history 

• Appetite:Decreased 

• Diet:Mixed 

• Regular bowel habits and normal 

• Patient has oliguria and burning micturition 

• He is an alcoholic since 10 years  , drinks once   weekly 

• Smoker since 25 years , he smokes daily 2-5 beedis 

 GENERAL EXAMINATION 

   Patient is conscious coherent and cooperative  , moderately built , moderately nourished 

⁃ Presence of pallor 

⁃ No icterus , no cyanosis, no clubbing ,no pedal edema 

⁃ No generalized lymphadenopathy     

  

   

 

 

 Vitals 

⁃ Pulse taken  in sitting position ,left radial pulse ,Pulse rate : 80bpm , regularly regular 

⁃ Bp 130/80 mm hg measured in sitting position on right upper arm 

⁃ Respiratory rate : 20cpm

⁃ Afebrile 

 

RESPIRATORY SYSTEM EXAMINATION 

 

 Patient is examined in supine as well as in sitting positions under well ventilated room with consent taken 

 Upper respiratory tract :

     nose , oral cavity  are examined and no abnormal findings are present 

 Examination of chest 

 Inspection 

⁃ shape of chest : normal 

⁃ Symmetry of chest : symmetrical 

⁃ Trial sign negative 

⁃ Movements of chest : RR -20cpm                  .  

                         Type - abdomino thoracic.                        

  .                      Equal on both sides 

⁃ No involvement of accessory muscles and no intercostal tenderness 

⁃ No visible scars , no sinuses , no engorged veins 

⁃ No deformities of spine 

⁃  No visible apical impulse 

PALPATION 

 

⁃ No tenderness and no local rise of temperature 

⁃ Inspectory findings are confirmed

⁃ Trachea is central 

⁃ Apex beat : felt at 5th Intercoastal space  medial to mid clavicular line

⁃ Decreased  chest expansion 

⁃ Vocal fremitus : decreased  at infra axillary and infra scapular areas on both sides                                       normal on supra clavicular , infraclavicular ,mammary , infra mammary , suprascapular and interscapular areas

 

PERCUSSION

1. Direct percussion: resonant on clavicle , sternum
2. Indirect percussion :  

  Anterior:

 Resonant in supra clavicular area 

 Resonant in infraclavicular  area 

 Resonant  in inframammary area on both   sides 

 Traube’s space:dull  

  Posterior:

 Resonant in suprascapular area 

 Resonant in interscapular area 

 Dull in Infrascapular area on both sides 

AUSCULATION 

1.Bilateral air entry present 

2.Normal vesicular breath sounds heard 

Reduced in  B/ L infrascapular  and infra axillary areas 

        -       fine crepts heard on B/L infra axillary and infra scapular areas 

 

CVS EXAMINATION 

 

⁃   S1 S2 heard 

⁃ No murmurs 

⁃ No palpable  thrills 

ABDOMINAL EXAMINATION 

 Scaphoid shape 

No tenderness 

No palpable mass 

No hepatosplenomagaly 

No ascites 

Bowel sounds  present 

CNS EXAMINATION 

⁃  Conscious and alert 

⁃ Normal gait 

⁃ Normal speech 

⁃ No signs of meningeal irritation 

⁃ Cranial nerves , motor system , sensory 

⁃ Reflexes : superficial and deep tendon reflexes are intact 

INVESTIGATIONS 

⁃ CBP

⁃ CUE

⁃ Abg 

⁃ RFT 

⁃ LFT

⁃ PT

⁃ APTT

⁃ Blood sugar 

⁃ ESR 

⁃ Serum pottasium 

⁃ Blood culture 

⁃ Chest x ray 

⁃ Ecg 

⁃ Ultrasound abdomen 

    

 

Provisional diagnosis :ACUTE ON CHRONIC  RENAL FAILURE with past history of  

pulmonary tuberculosis

Treatment

1.Salt and fluid restriction 

        Salt - < 2 g/ day 

        Fluid - < 1 lt / day 

2.Injection  IV LASIX 40mg BD 

3.Tab NODOSIS  500mg bd 

4.Tab SHELCAL 500mg od

5.Input and output charting 

6.Bp  pulse  spo2 charting