Long case-1601006156

April 28, 2021

Long case-1601006156

Hall ticket number-1601006156

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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:

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 months
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).

JVP is raised.

Arteriovenous fistula for haemodialysis is present on left forearm with palpable thrill.

CVS 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.

Palpation:

All the inspectory findings are confirmed.
Apex beat is in left 5th intercostal space,5cm lateral to the midclavicular line.
No palpable murmurs.
Carotid artery pulsations normal,no thrill present.

Auscultation: