A 45 YEAR OLD MAN WITH C/O S.O.B & SWELLING IN THE LEGS

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here, we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.


A 45 year old gentleman,from ramanapet who is a farmer by occupation came to the hospital with the chief complaints of:

• Shortness of breath since 1 year.

• Swelling of both feet, ankles and legs since 3

months.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 year back then he developed:

1. Shortness of breath

• Insidious in onset..

• Duration-1 year.

• Gradually progressive(initially grade 2 NYHA, and has gradually progressed to breathlessness at rest-grade 4 NYHA)

. • Orthopnea since 1month

Breathlessness increases on lying down position which was relieved on sitting in upright position.

• Associated with paroxysmal nocturnal
dyspnea.

2.Swelling of both feet, ankles and legs

• Insidious in onset.

• Duration-3 month

• Gradually progressive (started in feet and ankles and progressed to legs upto the level of knees). 

Aggravated on walking and less on elevating the legs.

=~ Other complaints:

• Decrease in urine output since 1 month.

• There is history of weight loss present (65kg to 58 kg).

• There is no history of chest pain,palpitations or syncopal attacks.

• No history of fever,sore throat and joint pains. • No history of hemoptysis and wheezing.

• No history of bluish discoloration of
face/oral cavity.

• No history of pain abdomen/jaundice. 

PAST HISTORY:

• He was diagnosed with hypertension 2 years back and is prescribed Nicardia 20 mg. But he discontinued taking medication since 1 year.

• He was met with a road traffic accident 3 years back, underwent a surgery on his right leg. He was taking analgesics regularly for 1 year.

• He is diagnosed with CKD and is on dialysis since 1 month.

• No history of diabetes mellitus, tuberculosis, asthma and epilepsy.

PERSONAL HISTORY:

• He takes a mixed diet.

• His appetite is normal.

Sleep is disturbed because of orthopnea and breathlessness is relieved in semi recumbent position.

• Decreased urine output since 1 month.

• Bowel movements are regular.

• Consumes alcohol occasionally since 20 years. 

FAMILY HISTORY:

• No history of similar complaints, hypertension, diabetes, TB in the family.

TREATMENT HISTORY:

History of usage of analgesics for a year.

• Nicardia-20 mg for hypertension.

GENERAL EXAMINATION:

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

Pallor-present.

• No signs of icterus,cyanosis, clubbing,koilonychia or lymphadenopathy.

• Bilateral pedal edema present extending upto the level of knees

Pitting type of edema.

Grade 3(about 5 mm of depression taking more than 30 seconds to rebound). 
Arteriovenous fistula for haemodialysis is present on left forearm with palpable thrill.
VITALS:
PR:84bpm, regular, normal volume
BP:130/80mm Hg, right arm sitting position
RR:23cpm
TEMP: Afebrile

CARDIOVASCULAR SYSTEM examination: 

INSPECTION:

•Shape of the chest normal.

• Trachea appears to be in midline.

• Visible apical impulse is present lateral to the midclavicular line.

• No engorged veins on the chest.

• No scars or sinuses are visible.
• No visible epigastric pulsations.

 • JVP is raised


 PALPATION:

• All the inspectory findings are confirmed.

• Apex beat is in left 5th intercostal space,5cm lateral to the midclavicular line.

• Apex beat is heaving??

• No palpable murmurs.

• Carotid artery pulsations normal,no thrill present.

PERCUSSION:

Right heart border shifted 1 cm right  from the right sternal border.
Left heart border shifted 4 to 5 cm lateral to midclavicular line.


AUSCULTATION: 
S1 & S2 : heard
 
No Murmurs 

Per Abdomen:

Inspection-

Abdomen- distended 

Umbilicus -Central in position and slit like

flanks are full

no sinuses, scars or visible pulsations 

hernial orifices are free.

Palpation :

no local rise in temperature 

no tenderness 

no guarding and rigidity 

no palpable masses.



Percussion:

shifting dullness- present

liver span-normal



Auscultation:

bowel sounds are heard.



Respiratory system :

bilateral air entry- present

normal vesicular breath sounds heard 

basal crepitations present in both the lung fields.



Central nervous system- normal.



INVESTIGATIONS:

CBP- 

Hemoglobin- reduced

PCV- reduced 

RBC count -reduced 



CUE-

Albumin in urine

RANDOM BLOOD SUGAR-
X-RAY:
RFT:

 Serum urea and creatinine- raised
LFT:
 SERUM IRON: 
USG ABDONEN:
Grade-II renal parenchymal disease


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

PROVISIONAL DIAGNOSIS:

HEART FAILURE WITH CHRONIC KIDNEY DISEASE.

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