hall ticket no : 1601006133 General medicine final year practical long case a 46 year old male shortness of breath pedal edema since 1week
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Case : 46 year old male patient from bopparam labourer by occupation came to the OPD the chief complaint of shortness of breath bilateral pedal edema and oliguria since 1 week
History of presenting illness patient was apparently asymptomatic 1 week ago and then he developed the shortness of breath which was insidious in onset gradually progressive
Bilateral pedal edema since 1 week pitting type.
H/o decreased urine output
No h/o of chest pain, cough, expectoration , hemoptysis, reccurent respiratory tract infections
No h/o palpitations, syncope, fever.
No h/o burning micturition , hematuria
No history suggestive of hypo or hyperthyroidism
Past history ::
No similar complaints in the past
known case of Hypertension since 4yrs( diagnosed when went to local rmp) and diabetes since 2yrs and is on regular medication.
Not a known case of asthma, tuberculosis and epilepsy.
The patient is on dialysis maintenance since 1 year
Personal history :
-Consumes mixed diet
-Normal appetite
-Sleep-adequate
-Bowel and bladder are regular
-He is a chronic alcoholic consumes 90 ml per day since 11yrs
-No habit of smoking and tobacco and Pan chewing
Family history::
No similar illness in the family
Lower socioeconomic status
No significant family history
General examination :
Patient is conscious, coherent, cooperative , oriented to time place person comfortably lying on bed
moderately built and nourished.
pallor present
edema present 
No signs of icterus cyanosis clubbing koilonychia ,generalised lymphadenopathy,
JVP- raised
VITALS pulse 78 /min no radio radial delay and radiofemoral dealy
Blood pressure 150 /90 mmHg right arm supine position
No significant postural fall
Respiratory rate 20 cycles per minute
Temperature afebrile
Local examination of cardiovascular system ::
Inspection :
shape of the chest normal , symmetrical ,no deformity
Trachea appear to be central ,no precordial bulge
No visible impulses scars sinuses dilated veins in any part of the thorax
Palpation : all inspectory findings confirmed by palpation
Trachea is central
Apex beat is felt in 6th intercostal space leteral to midclavicular line
palpable p2
No palpable heart sounds and murmurs
No palpable pericardial rub
Percussion :
Dull note is heard along the heart borders
Auscultation : S1 S2 heard no murmurs
Respiratory system ::bilateral air entry present
Normal vesicular breath sounds heard no added sounds
Per abdomen :soft ,non tender, no organomegaly ,no free fluid
Bowel sounds heard
Hernial orifices are free
CNS:: NO FOCAL NEUROLOGICAL DEFICIT
INVESTIGATIONS
HEMOGRAM : hemoglobin reduced
Complete urine examination proteinuria present albumin present 4+ sugar present in urine
Renal function test urea and creatinine raised
Liver function test
ECG
Heart rate : 74bpm
Ultrasound report. Renal parenchymal disease grade II
Provisional diagnosis :: Heart Failure secondary to chronic kidney disease
Treatment history ::
TREATMENT:
SALT AND FLUID RESTRICTION
TAB. NICARDIA 10MG T.I.D
TAB. LASIX 40MG B.D
TAB. ARKAMIN 100MG
TAB. UNIFER
CAPSULE. GEL CAL D3
A.V Fistula:-
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