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

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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