hall ticket no. 1601006117 Short case - medicine
Presented by - hall ticket no. 1601006117
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A 40year old male patient resident of tummatuti, farmer by occupation,
Presented to OPD with chief complaints of
- Shortness of breath since 6 days
- Bilateral pedal oedema since 4 days
Patient was apparently asymptomatic 6 days ago, then he developed shortness of breath , which was insidious in onset and gradually progressed from grade 2 to grade 3.
Then he developed bilateral pedal oedema , pitting time, insidious in onset and gradually progressive, not relieved on elevation of legs, persent through out the day and increased on walking. No relieving factors.
No H/o decreased urine output, paroxysmal nocturnal dyspnoea, cough and expectoration, chest pain, no history of palpitations and syncope No history of fever, sore throat, joint pains. No hemoptysis, hematemesis, no history of Jaundice, no history of burning micturition, no h/o weight loss.
Past history:
history of similar complaints 4 months ago
K/c/o hypertension since 12 years
H/o NSAID abuse since 7 years
K/c/o diabetes mellitus since 7 years
K/c/o chronic kidney disease since 4 months
Patient has undergone 6 sessions of dialysis till now
Not a k/c/o TB , EPILEPSY, asthma.
Family history : not significant
Personal history:
Diet : mixed
Appetite : normal
Sleep: adequate
Bowel and bladder : c/o constipation.
Was a chronic smoker and alcoholic till the age of 30 years,
no known drug allergies
General physical examination:
Patient is conscious, coherent , co-operative, moderately built ,and moderately nourished.
Pallor: absent
Icterus : absent
Cyanosis: absent
Clubbing: absent
Koilonychia: absent
Lymphadenopathy: absent
Edema : bilateral pedal oedema present
Vitals:
Patient is afebrile
Pulse : 90 beats/min
Respiratory rate : 20 cycles / min
BP : 140/90 mm hg
SpO2: 95%
GRBS: 140 mg/dl
CNS examination:
Higher mental functions-normal
Cranial nerves- intact
Sensory system- normal
Motor system- normal
Meningeal signs- absent
Cerebellar signs- absent
Respiratory system examination:
Inspection of upper respiratory system-
oral cavity- normal
Nose- normal
Pharynx- normal
Lower Respiratory Tract:
Inspection:
trachea: central
Symmetry of chest : symmetrical
Movement: B/L symmetrical expansion of chest respiration
No scars, engorged veins or sinuses.
Palpation:
All inspectory findings are confirmed by palpation.
Trachea: central - confirmed by three finger test.
Assessment of anterior and posterior chest expansion- B/L symmetrical expansion of chest.
No chest wall tenderness
Vocal fremitus- normal
Percussion :
done in sitting position and when patient is lying down
Resonant
Auscultation:
Vesicular breath sounds heard
Bilateral air entry present
No added sounds
CVS examination:
Inspection :
No scars sinuses and engorged ve
No visible pulsation
Palpation:
apical impulse : felt in fifth inter coastal spac
Auscultation:
S1 and S2 heard
No murmurs heard
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.( No organomegaly )
Percussion:
shifting dullness- present
liver span-normal
Auscultation:
bowel sounds are heard.
Investigations:
Iron sucrose inj. 100mg in 100 ml normal saline
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