Gm case 3


CASE SCENARIO..
Hi,I'm C.Srivally,3rd bds student.This is an online elog book to discuss our patients health data after talking his consent.This also reflects my patient centered online learning portfolio.
                  CASE HISTORY 
Chief complaint:
A 39 year old male presented with chief complaints of 
shortness of breath since since 6 months 
Generalised body swelling since 6 months
Decreased urine output since 6 months 
HISTORY OF PRESENT ILLNESS 


Patient was apparently asymptomatic 3 and half years back ,

then the patient had an episode of giddiness ,due to shock (from the death of his brother in law) ,for which he went to a local hospital and got diagnosed with hypertension.

Since then he was started on medication.He used to take the medication only when there's occasional neck stiffness and pain.

History of mild shortness of breath and chest pain 2 years back, which is not associated with cough or fatigue for which he went to a local hospital where he was told to have uncontrolled blood pressure.

Since then complaints were decreased in frequency but did not subsided.

Shortness of breath worsened 18 months back from exertion to even at less than ordinary activity  Grade 2 to 3 which is associated with bilateral pedal edema, pitting type, upto the knees.

H/o fever 16 months back, associated with cough and weight loss cough relieved with medication.

In February 2022 patient presented to our hospital with complaints of worsened shortness of breath even at rest, Diagnosed to have Acute pulmonary edema secondary to heart failure and Renal Failure. Symptoms relieved and patient discharged with online follow up.


8 months back in view of refractory pulmonary edema and metabolic acidosis patient was initiated on hemodialysis and continuing maintainance hemodialysis regularly with frequency of 2-3 times per week.

Current admission:

Patient presented with Shortness of breath at rest and intermittent generalised body swelling and distension of abdomen since 6 months 

Fever since 1 month

Shorteness of breath initially on exertion which gradually worsened even at rest associated with distension of abdomen.


Fever which is high grade, intermittent type associated with chills not associated with nausea, vomiting, altrered sensorium, cough and burning micturation.


PAST ILLNESS 

No similar complaints in the past.

No significant medical or surgical history

Not a known case of DM, bronchial asthma, CAD, Epilepsy


FAMILY HISTORY:


 No family history of HTN, DM, bronchial asthma, epilepsy


PERSONAL HISTORY :


Sleep disturbances since 6 months

Appetite improved since dialysis but decreased since distension of abdomen

Decreased urine output and no constipation.

Patient is a chronic alcoholic and chronic smoker since 15 years

Alcohol 90-150 ml per day whiskey/brandy 

1-2 beedi per day for 15 years

Tobacco chewing daily Since 15 years 


Examination : 


Patient is conscious, coherent, cooperative.

Thin built and moderately nourished.

Pallor  yes

Icterus no

Clubbing yes

Cyanosis yes

Lymphadenopathy no

Edema yes


Systemic examinations:


Respiratory system:

Inspection:

Upper respiratory tract -oral cavity,nose,oropharynx appears normal

Chest appears bilaterally symmetrical, elliptical in shape

Respiratory movements appear equal on both sides

Trachea Central in position and nipples are in 4th intercoastal space

No dilated veins ,scars,sinuses, visible pulsations

Palpation:

Trachea Central in position

Apical impulse in 5th intercoastal space 1cm medial to mid clavicular line 

Chest circumference -31 inches at expiration 32 inches at full inspiration

Ap diameter 7 inches

Transverse diameter 12 inches

Percussion:

Supraclavicular-Resonant

Infraclavicular-Resonant

Mammary-Resonant

Infra axillary -Dull

Suprascapular-Resonant

Interscapular-Resonant

Infrascapular-Resonant

Auscultation:

Supraclavicular-Normal vesicular breath sounds

Infraclavicular: Normal vesicular breath sounds

Axillary -Normal vesicular breath sounds

Infraaxillary-wheezing breath sounds

Suprascapular-Normal vesicular breath sounds 

Interscapular-Normal vesicular breath sounds

Infrascapular-wheezing breath sounds .


GIT EXAMINATION


Inspection:

Shape -Distended abdomen

Umbilicus-Everted

Equal symmetrical movements in all quadrants with respiration

No visible pulsations ,no scars

Palpation:

Local rise of temperature

Percussion:

Fluid thrills are present and shifting dullness 

Auscultation:

Bowel sounds are not heard 






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