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A 45 year old male resident of Nalgonda labourer by occupation presented with chief complaint of : 

 • shortness of breath since 10 days  

 • Cough since 10 days 

 • Pedal edema since 10 days 



History of presenting illness  


Patient was apparently asymptomatic 10 days ago,then developed —

 • Grade III shortness of breath which was insidious in onset , nonprogressive,aggravated by walking and strenous work and dressing , relieved by sitting             

               There is history of orthopnea                        

               There is no history of PND 

 • Dry Cough since 10days which is insidious in onset , non progressive ,no aggrevating and relieving factors 

 • Grade III bilateral Pedal edema since 10 days which in insidious in onset , gradually progressive,pitting type , no aggravating and no relieving factors 

        . fever since 10 days which is insidious in onset ,with evening rise of temperature , intermittent , not associated with chills and rigors , headache , vomiting 

 • History of burning micturition and oliguria since 5 days 

 • There is no history of sweating , palpitations , chestpain , hematuria 


Past history 

 • 2 years back he developed symptoms of productive cough and fever for 1 week for which he visited to hospital and diagnosed with TUBERCULOSIS and took antitubercular drugs for 6 months and at that time he was told be having some kidney issues and used some medications ( records notavailable ) 

 • Not a known case of diabetes ,hypertension,asthma , convulsions

 • Surgical history is not significant.      


Family history 

          Not significant 


Personal history 


 • decreased appetite 

 • Mixed diet

 • Regular bowel habits and normal 

 • Patient has oliguria and burning micturition 

 • He is an alcoholic since 10 years , drinks once weekly 

 • Smoker since 25 years , he smokes daily 2-5 beedis 


 GENERAL EXAMINATION 


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

 ⁃ Presence of pallor 

 ⁃ No icterus , no cyanosis, no clubbing ,no pedal edema 

 ⁃ No generalized lymphadenopathy     







  


   


 

 








 Vitals 

 ⁃ Pulse taken in sitting position ,left radial pulse ,Pulse rate : 80bpm , regularly regular 

 ⁃ Bp 130/80 mm hg measured in sitting position on right upper arm 

 ⁃ Respiratory rate : 20cpm

 ⁃ Afebrile 

 

RESPIRATORY SYSTEM EXAMINATION 

 

 Patient is examined in supine aswell as in sitting positions under well ventilated room with consent taken 


 Upper respiratory tract :

     nose , oral cavity are examined and no abnormal findings are present 


 examination of chest proper :

Inspection  

 ⁃ shape of chest : normal 

 ⁃ Symmetry of chest : symmetrical 

 ⁃ Trial sign negative 

 ⁃ Movements of chest : RR -20cpm .  

                         Type - abdomino thoracic.                        

  . Equal on both sides 

 ⁃ No involvement of accessory muscles and no intercoastal tenderness 

 ⁃ No visible scars , no sinuses , no engorged veins 

 ⁃ No deformities of spine 

 ⁃ No visible apical impulse 





palpation 

 ⁃ No tenderness and no local rise of temperature 

 ⁃ Inspectory findings are confirmed

 ⁃ Trachea central 

 ⁃ Apex beat : felt at 5 th Intercoastal space medial to mid clavicular line

 ⁃ Decreased chest expansion 

 ⁃ Vocal fremitus : decreased at infra axillary and infra scapular areas on both sides normal on supra clavicular , infraclavicular ,mammary , infra mammary , suprascapular and interscapular areas 

.


  Percussion 

Direct percussion: resonant on clavicle , sternum 

    2. Indirect percussion : 

  Anterior :

 ⁃ resonant in supra clavicular area 

 ⁃ Resonant in infraclavicular area 

 ⁃ Resonant in inframammary area on both sides 

 ⁃ Traube’s space:dull  

  Posterior :

 ⁃ Resonant in suprascapular area 

 ⁃ Resonant in interscapular area 

 ⁃ Dull in Infrascapular area on both sides 


Auscultation   

 ⁃ Bilateral air entry present 

 ⁃ Normal vesicular breath sounds heard 

  Reduced in B/ L infrascapular and infra axillary areas 

        - fine crepts heard on B/L infra axillary and infra scapular areas 

 

CVS EXAMINATION 

 

 ⁃ S1 s2 heard 

 ⁃ No murmurs 

 ⁃ No palpable thrills 


ABDOMINAL EXAMINATION 


 Scaphoid shape 

No tenderness 

No palpable mass 

No hepatosplenomagaly 

No ascites 

Bowel sounds present 


CNS EXAMINATION 


 ⁃ Conscious and alert 

 ⁃ Normal gait 

 ⁃ Normal speech 

 ⁃ No signs of meningeal irritation 

 ⁃ Cranial nerves , motor system , sensory 

 ⁃ Reflexes : superficial and deep tendon reflexes are intact 


INVESTIGATIONS 


 ⁃ CBP

 ⁃ CUE

 ⁃ Abg 

 ⁃ RFT 

 ⁃ LFT

 ⁃ PT

 ⁃ APTT

 ⁃ Blood sugar 

 ⁃ ESR 

 ⁃ Serum pottasium 

 ⁃ Blood culture 

 ⁃ Chest x ray 

 ⁃ Ecg 

 ⁃ Ultrasound abdomen 

  




    










 


Provisional diagnosis :ACUTE ON CHRONIC RENAL FAILURE with past history of pulmonary TUBERCULOSIS 


TREATMENT 


 ⁃ Salt and fluid restriction 

        Salt - < 2 g/ day 

        Fluid - < 1 lt / day 

 ⁃ Injection iv LASIX 40mg BD 

 ⁃ Tab NODOSIS 500mg bd 

 ⁃ Tab SHELCAL 500mg od

 ⁃ Input and output charting 

 ⁃ Bp pulse spo2 charting 


 














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