G.KRUPALATHA. HALL TICKET NO: 1601006060. LONG CASE.

This is an online E log book to discuss our patient\"s de -identified health data shared after taking his/her/guardian\"s signed informed consent. Here we discuss our individual patient\"s problems through series of inputs from available global online community of experts with an aim to solve those patient\"s clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment

HALL TICKET :1601006060.


A 45 year old male resident of Nalgonda labourer by occupation presented to our opd on 20 april  with chief complaint of : 
         .      Pedal edema since 15 days 
         .      Oliguria since 15 days
         .     Burning  micturition since 10 days
         .      Fever since 10 days
• shortness of breath since 8 days  
• Cough since 8 days 
   

History of presenting illness :-

 Patient was apparently asymptomatic 15 days ago,then developed —
 
• Bilateral pedal edema,     since 15 days which in insidious in onset , gradually progressed up to the thighs, pitting type , no aggravating and no relieving factors 

. Decreased urine output  since 15 days.
 
. There is history of fever since 10 days which is insidious in onset , intermittent , not associated with chills and rigors , headache , vomiting .

.History of burning micturition and oliguria since 10 days 

 . Shortness of breath since 8 days   which was insidious in onset, non progressive, aggrevating by walking and sternous work and relieved by taking rest.
( Grade lll ).
He has history of orthopnea.
There no history of PND.

.Dry cough :-
He has dry cough since  8 days, which is insidious in onset, non progressive, no aggrevating and relieving factors.

  . His appetite has decreased.

• There is no history of sweating , palpitations , chestpain , hematuria 
  *  patient underwent 2 sessions of  Dialysis  after admitting in our hospital.
 
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  





 
 





 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 lateral 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 
  1. 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 , glasgowcoma scale normal 
⁃ Reflexes : superficial and deep tendon                  reflexes are intact 
 
Provisional diagnosis :
ACUTE ON CHRONIC RENAL FAILURE with past history of pulmonary TUBERCULOSIS . 
 
INVESTIGATIONS 

⁃ CBP
⁃ CUE
⁃ ABG
⁃ RFT 
⁃ LFT
⁃ PT
⁃ APTT
⁃ Blood sugar 
⁃ ESR 
⁃ Serum pottasium 
⁃ Blood culture 
⁃ Chest x ray 
⁃ ECG 
⁃ Ultrasound abdomen 



    






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 
⁃ Nebulization with mucomist and                            BUDICORT 12 th hrly 
⁃ Bp  pulse  spo2 charting 

 








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