1801006011 - LONG CASE
48 year Male came to the medicine OPD with chief complaints of
- Difficulty in breathing since 2 days
- decreased urinary output since 2 days
- Swelling of lower limbs on and off since 1 year
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic then he developed bilateral pedal edema on and off in nature since 1 year from knee to ankle region, and was on conservative treatment. He went to local hospital and was diagnosed with hypertension and started using medication (drug-Telmisartan dosage-40mg)since 1 year.
2 days ago at night patient developed sob sudden in onset and gradually progressive, class 3, associated with orthopnea.
associated with PND
urine output was narrow streamlined urine
history of intermittent fever not associated with chills and rigor
not associated with chest pain
not associated with sweating
no history of burning micturition
DAILY ROUTINE
patient wakes up at 530 in the morning and does his household chores and goes to work daily work for 5 hours and comes back between 12-1 pm to have lunch, and takes rest for the day. Patient have dinner at around 730 in evening and goes to sleep at 9pm.
PAST HISTORY
Known case of hypertension
No similar complaints in the past
Not a known case of DM, asthma, epilepsy, thyroid disorders.
DRUG HISTORY
Started using Telmisartan 40 mg since 1yr
FAMILY HISTORY
No similar complaints in the past
PERSONAL HISTORY
Appetite Normal
Diet mixed
Sleep Adequate
Bowel and bladder Regular, Decreased micturition
Addictions Smoking history -beedi consumer (4 beedis per day so 6 pack years)
Alcohol history -since 25 years 4 times monthly(whisky 90 ml each time)
GENERAL EXAMINATION
Patient is consious, coherent, and cooperative
moderately built and moderately nourished
Pallor - present
Icterus-absent
Cyanosis - absent
Clubbing-absent
Lymphadenopathy -absent
Pedal edema -absent
vitals
Temperature - Afebrile
Pulse - 76 bpm
Blood pressure- 130/80 mmhg
Respiratory rate- 17 cycles per min
Spo2 - 95%
SYSTEMIC EXAMINATION
CVS-
Inspection
No palpitations
JVP no
Palpation
Apex at 6th intercoastal space
No parasternal heave
No palpable P2
Auscultation
S1 S2 heard
RESPIRATORY SYSTEM
No scars, pulsation, engorged veins.
lesion present on beside right nipple
chest is bilaterally symmetrical
shape of chest - elliptical
bilateral airway entry present
trachea - Midline
Auscultation- wheezing and Krebs heard diffusely around chest
Percussion-
right left
supra clavicular resonant resonant
infra clavicular resonant resonant
supra mammary resonant resonant
infra mammary resonant resonant
axillary resonant resonant
supra axillary resonant resonant
infra axillary resonant resonant
supra scapular resonant resonant
infra scapular resonant resonant
ABDOMINAL EXAMINATION
shape- scaphoid
tenderness no
no palpable mass
liver not palpable
spleen not palpable
CNS EXAMINATION
speech normal
no focal neurological deficits seen
INVESTIGATIONS
Complete blood picture
hemoglobin - 8.6 gm/dl
total count - 19,200cells/cumm
neutrophils - 91%
lymphocytes - 3%
pcv - 27.6%
blood group A+
interpretation- Normocytic normochromic anemia with neutrophilic leukocytosis
URINE EXAMINATION
albumin ++
sugar nil
pus cells 2-3
epithelial cells 2-3
Red blood cells 4-5
random blood sugar - 124 mg/dl
Renal functional test
urea 154/dl
creatinine 5.9mg/dl
uric acid 8.7 mg/dl
sodium 133mEq/L
Serum Iron- 74 ug/dl
Liver functional test
Alkaline phosphate 312 mg/dl
total protein 6.2 gm/dl
albumin 3.04gm/dl
ABG ANALYSIS
pH - 7.13
pCO2 - 34.1 mmHg
pO2 - 54.6 mmHg
HCO3 -11.1 mmol/L
O2 saturation 95.9%
GENERAL EXAMINATION FINDINGS
PROVISIONAL DIAGNOSIS
- Ryles feed -100ml milk +protein powder 2 scoops
- Neb. Budecort and duolin 8hrly
- Inj. piptaz 2.25 gm iv-TID
- Inj.Lasix 40mg IV/BD
- Inj.Pan 40mg IV/OD
- Inj.Hydrocort 100 mg IV/BD
- Tab.Telma H
- Dialysis
- strict I/O charting
- Monitor vitals
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