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

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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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