A 28 YEAR OLD GENTLEMAN WITH FEVER,SOB,PEDAL EDEMA, ABDOMINAL DISTENSION AND DECREASED URINE OUTPUT.
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CHIEF COMPLAINTS: A 29 year old male unmarried who is a daily wage labourer resident of Nalgonda, came to hospital with chief complaints of on & off fever since 2 yrs , shortness of breath , b/l pedal edema , abdominal distension and decreased urine output since 1 year
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 2years ago and then one day he developed
fever (high grade , continuous , associated with chills & rigors) and generalized body aches for which he went to a local RMP and he prescribed some tablets.
Fever subsided temporarily and he used to get fever at night.
So he went to a local hospital in nalgonda where they prescribed him some pain killers for his body pains & fever which he continued to take daily for nearly 5-6 months (2-3 tablets/day).
Inspite of that he had on & off fever & pedal edema(b/l pitting type extending upto knees) for which he went to NIMS,where several investigations where performed. He then underwent kidney biopsy due to abnormal RFT's and was diagnosed with primary focal segmental glomerulo sclerosis.
2 months later he had increasing pedal edema associated with decreased urine output , abdominal distension and SOB grade 2-3, for which dialysis was advised & that was when he came to our hospital. From then onwards he was on maintainence hemodialysis.
He has also been started on empirical ATT even though his sputum turned out to be negative because of the long standing history of fever, cough and around 10 kgs of weight loss in 7 months. After initiating ATT, his blood pressure couldn't be under control so decision was made to put Rifampicin on hold.
From the past 5-6 months SOB has been increasing gradually to grade-4 with associated orthopnea & PND.
No h/o chest pain/palpitations/chest tightness
No h/o fever/cough at present
No other complaints
PAST HISTORY:
Hypertension since 1 year
No h/o DM/ asthma/epilepsy/CAD
PERSONAL HISTORY :
Mixed diet
Disturbed sleep
Decreased appetite
Normal bowel & bladder habits
No addictions
FAMILY HISTORY:
No relevant family history seen .
GENERAL EXAMINATION:
Patient is conscious , coherent and cooperative.
Oriented to time, place and person.
He is moderately built and moderately nourished.
VITALS:
Temperature: afebrile
Blood pressure: 130/90mm Hg
Resp rate:12 cycles per min
Pulse rate : 82bpm
Pallor : Present
Icterus : absent
Clubbing: not present
Koilonychia: not present
Lymphedenopathy: not present
Edema : present in lower limbs
GENERAL INSPECTION :
JVP raised
Scar of failed AV fistula - arterialization of veins
So they planned dialysis on femoral vein
CVS EXAMINATION:
INSPECTION:
Examination of neck
Carotids : bilaterally visible
JVP : elevated
Trachea in the midline
Visible apex beat
PALPATION:
Trachea midline
No carotid bruit
thrill present at tricuspid area
Palpable P2
Apex beat :At left 6th intercostal space lateral to midclavicular line
No suprasternal ,epigastric and Interscapular impulses.
PERCUSSION:
Rt heart border corresponding to rt sternal border
Rt & lt 2nd intercostal spaces are resonant.
AUSCULTATION:
S1 S2 heard
P2 loud
High pitched grade 4 Pansystolic murmur heard on mitral and tricuspid area.
ABDOMINAL EXAMINATION:
Distended abdomen
Umbilicus everted
shifting dullness/fluid thrill present
No visible scars/sinuses/pulsations
No tenderness
No organomegaly
Bowel sounds heard
RESPIRATORY SYSTEM EXAMINATION:
Elliptical & bilaterally symmetrical chest
Both sides moving equally with respiration
Resonant note heard in all areas
Bilateral air entry present
Normal vesicular breath sounds
Fine crepitations heard in right infra axillary & infra scapular areas
CENTRAL NERVOUS SYSTEM EXAMINATION:
Higher mental functions intact
Sensory & motor system normal
Cranial nerves intact
Reflexes present
No focal neurological deficit
LAB INVESTIGATIONS:
Complete blood picture
RENAL FUNCTION TESTS :
RFT interpretation: urea ,creatinine and uric acid levels are elevated .
Random blood sugar are in normal range.
CHEST X RAY:
ULTRASONOGRAPHY ABDOMEN
ELECTROCARDIOGRAPHY:
Left axis deviation and left ventricular hypertrophy are interpreted on ECG.
DIAGNOSIS: Based on the history,clinical features , examination and laboratory findings my diagnosis is
CHRONIC KIDNEY DISEASE WITH HEART FAILURE.
MEDICATIONS:
7am - T Nicardia 20mg ( nifidipin)
Arkamine 0.1mg (clonidine)
Met XL 50mg ( metoprolol succinate)
Lasix 80mg ( furosemide)
Spironolactone 25mg
Between 1:30 - 2pm
T Arkamine 0.1mg
Nicardia 20mg
6pm
T Lasix 80mg
8pm
T Arkamine 0.1mg
Met XL 50
Lasix 80mg
Spironolactone 25mg
Nicardia 20mg
Shelcal 500mg ( calcium with vitamin D)
His blood pressure observation after starting medications
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