1801006096- LONG CASE

Htno:- 1801006096

March 17th 2023.

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LONG CASE

A 50 year old male presented with chief complaints of SOB and pedal edema since 10 days.

History of presenting illness:-

Patient was apparantly asymptomatic 1year back. Then he  developed SOB grade 4 which is intermittent and with that he diagnosed with CKD 1 year ago.

Bilateral pedal edema which is pitting type.

Apparantly asymptomatic 14 years ago,(2008) then he had a history of fall from tree for which he got backpain and then used medication for that.later,8 years ago (2015), he was diagnosed with type-2 diabetes mellitus. History of TB 2years ago and used ATT for 6months.

Seasonal SOB and wheeze on and off since 3 years, with CKD 1 year ago.

Increased SOB and edema since 10 days.

He stopped going to work since last 3 years due to pain and intermittent SOB.

Past history:—

K/c/o TB 2years ago

K/c/o type2 DM since 8 years (on OHA)

K/c/o BP

No H/o Asthma and thyroid.

Personal history:—

Diet- mixed (with non-veg predominant)

Sleep-adequate

Appetite- decreased 

Bowel and bladder- decreased urine output.

Addictions- alcohol (daily)stopped 2years ago ,now occasionally 

Family history:- not relevant.

General examination:—

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

Pallor-absent 

Icterus-absent

Cyanosis-absent

Clubbing-absent

Lymphadenopathy-absent

Pedal edema- seen bilaterally (pitting type)

Vitals:—

Temperature- afebrile 

Pulse rate- 103bpm

RR- 35cpm

Blood pressure-150/90 mmhg

Grbs:- 203mg/dl

SpO2:- 97% @room air

Systemic examination:—

Cardiovascular system:-

Inspection:-

Appears normal in shape

Apex beat not visible

No scars , sinuses and dilated veins.

Mild JVP raise.

Palpation:—

All inspectory findings are confirmed

Trachea central in position.

Apex beat- 5th intercoastal space lateral to mid clavicular line.(1cm)

Percussion:-

Heart borders are within normal limits.

Auscultation:—

S1 and S2 heard.

RS:— BAE present

Trachea- centrally located

Shape of chest- bilaterally symmetrical and elliptical.

Percussion:— 

Dull note heard over left side. (In mammary,infraaxillary and infra scapular regions.)

Little dullness over right side. (In infraaxillary and infrascapular regions.)

Auscultation:—

NVBS are less heard in infraaxillary,infrascapular and inter scapular regions.

CNS:—

No abnormal deficits seen.

Per abdomen:- soft non tender

Bowel sounds heard.

Investigations:—

Hemogram:-

Hb- 11.4g/dl

Total count- 10000 cells /cumm

Neutrophils- 69%

Lymphocytes-18%

Monocytes-11%

Basophils-0

PCV- 35.7

MCV- 83.6

MCH- 26.7

MCHC- 31.9

No hemoparasites seen.

Ultrasound:—

USG CHEST: 

IMPRESSION:

BILATERAL PLEURAL EFFUSION (LEFT MORE THAN RIGHT) WITH UNDERLYING COLLAPSE.

2D echo:—

MR +ve, TR +ve (moderate)

Renal function tests:-

Urea- 64mg/dl

Creatinine- 5.9mg/dl

Spot urine protein- 34

Spot urine creatinine- 14.8

Electrolytes- 

Na- 139mEq/L

K-3.1 mEq/L

Cl-101mEq/L

Ca- 0.85 mmol/L.

Liver function tests:—

Total bilirubin-0.9mg/dl

Direct bilirubin-0-1mg/dl

Indirect bilirubin-0.8mg/dl

Alkaline phosphatase- 221 u/l

AST-40u/L

ALP- 81u/L

Total protein-6.8g/dl 

Albumin-4.2g/dl

Globulin-2.6g/dl

Albumin globulin ratio - 1.6

FBS— 93mg/dl

PLBS- 152mg/dl

ECG:-

Serology:—Hcv- non reactive.

ABG:—

PH- 7.3

PCo2- 28.0

PO2- 77.4

HCo3- 13.5 

X ray:—

Provisional diagnosis:-

-Heart failure with reduced ejection fraction.

With Acute kidney injury on chronic kidney disease (NSAID induced or diabetes induced).

And bilateral pleural effusion (left side is more than right side)

Treatment:—

-Fluid restriction less than 1.5lts per day.

-salt restriction less than 1.2gm perday

-INJ Lasix 40 mg IV/BD.

-TAB MET XL 25mg PO/OD

-TAB Cinod 5 mg PO/OD.

-INJ human actrapid insulin SC/TID

-INJ PAN 40 mg IV/OD

-INJ ZOFER 4mg IV

- vitals monitoring

-TAB Ecosprin AV 75/10 mg PO/HS.