1801006107 long case. 45 year old male patient with Heart failure.

 A 45 old male patient auto driver by occupation came to the OPD with cheif complaints of swelling in the both legs & shortness of breath since 5 days.

History of present illness:

Patient was apparently asymptomatic 5 days back then he developed increased swelling in both lower limbs which is pitting type of edema .insidious in onset gradual in progression. Swelling is up to the ankles . It is not seen above the ankles . 

patient also complains of shortness of breath which is insidious onset gradually progressive . It progressed from grade 2 to grade-4.Patient also complains of breathlessness in lying down position. Aggravated on activity and relived on rest . 

History of paroxysmal nocturnal Dyspnea is present 3 hours after patient sleeps and it is relieved when patient arises.

Patient also complains of fatigue on activity. 

No complaints of facial puffiness . 

No H/o chest pain , palpitations, syncope attack . 

No complaints of confusion , altered mental status , lack of concentration , memory impairment .

No complaints of abdominal pain . 

No H/O cough , sputum , hemoptysis, chest pain. 

No H/O burning micturation , increased frequency of urine , decreased urine output . 

Past history:

Similar complaints are seen 7 months back for which he is undergoing hemodialysis (twice aweek).


Patient is known case of diabetic since 6 years .Patient is also hypertensive since 5 years . No history of tuberculosis, asthma , epilepsy .

Treatment history:

 patient is taking insulin injections for the diabetes and for hypertension he is taking Tab clinidipine,Tab furosemide, Tab metaprolol . 

Personal history:

Appetite is normal, diet is mixed , bowel and bladder are regular, sleep is adequate, and no addictions & no allergies. 

Family history: 

no similar complaints in the family.

General examination: 

Patient is conscious,coherent & cooperative. Moderately built and well nourished , well oriented with time , place and person. 

Pallor is present 

No icterus , cyanosis , clubbing , lymphadenopathy. 

Pedal edema is present.

Vitals:

Temperature:98.6°f 

Pulse rate:82b/m

Blood pressure:130/80mmhg. 

Respiratory rate:18 cycles/min.


Systemic examination: 

CVS Examination: 

Inspection:

 JVP is raised. 

Chest wall is bilaterally symmetrical. No precordial bulge, no engorged veins over the chest wall , no engorged neck veins , tracheal position is central . No scars and sinuses . 

Palpation : 

Apex beat is present at the 8th intetcostal space 1cm lateral to the mid clavicular line . 

No pulsations, No parastetnal heave , No precordial or carotid thrill , No dilated veins . 

Percussion : normal

Auscultation: s1and s2 are heard and no murmurs. 


Respiratory system examination: 

Inspection: 

Upper respiratory tract : oral cavity , nose , pharynx are normal. 

Lower respiratory tract : 

Chest is bilaterally symmetrical , No chest deformities, No spinal deformities, Movements of the chest are symmetrical.

Palpation : 

Apex beat at the level of 8th intercostal space 1cm lateral to the midclavicular line . 

Trachea is central in position, Chest expansion is normal , expansion of chest is bilaterally symmetrical. No tactile Fremitus and No friction fremitus. Vocal fremitus is also normal.

Percussion : resonant.

Auscultation: 

Bilateral crepitations present in all areas . 

Vocal resonance is normal , No wheezing , No stridor , No pleural and pericordial rub . 

Per abdomen examination: 

Inspection: 

Abdominal distension is present . Fullness of flanks is seen . 

Umbilicus is inverted , all quadrants move equally with the respiration, No visible pulsations , No scars , sinuses , striae , stretched skin, No hernial orifices , No veins on the abdominal wall . 

Palpation : 

No rise of temperature and No tenderness over the abdomen . 

No enlargement of organs . 

Percussion : shifting dullness is present , No fluid thrill , No increase in the liver span . 

Auscultation: 

Bowel sounds are heard . 


CNS examination : 

Higher mental functions are normal .

Cranial nerves examination is normal . 

Motor system : 

1. Bulk : both right and left upper and lower limbs are normal . 

2.Tone : tone of both upper and lower limbs are normal . 

3. Power : power of neck muscles , upper limbs , lower limbs, trunk muscles are good . 

4. Reflexes : superficial reflexes are normal . 

Deep tendon reflexes : Biceps jerk , triceps jerk , ankle jerk , knee jerk are present . 

Normal gait and No involuntary movements. 

Sensory system : crude touch , pain , temperature, fine touch , vibration , position sense are normal . 

Cerebellar signs : Nystagmus , Dysarthria , Hypotonia are not present . 

No signs of meningeal irritation. 

Provisional diagnosis : Heart failure with pulmonary edema .






INVESTIGATIONS:

Hemogram:  

      Hb: 9.5gm/dl  ( 13-17)

    Mcv : 80.8fl  (83-101)

    Mch: 26.5pg  (27-32) 

   Rbc count : 3.59millions/cumm (4.5-5.5)




RFT:

         Urea : 56mg/dl (12-42)

         Creatinine : 6.8mg/dl (0.9-1.3)



LFT:

     Alkaline phosphate : 210IU/L (53-128)

      Albumin :3.23gm/dl (3.5-5.2) 


Serum iron: 60micrograms/dl .

ECG:


2D echo:



Chest x-ray : 

 

Revised diagnosis: Acute LVF - Flash pulmonary edema

Dilated cardiomyopathy. 

CKD .

Anemia of chronic disease. 

Treatment:

Bed rest .

Fluid restriction <1.5 lit/day

Salt restriction < 2gm/day

Inj.Lasix 40mg IV/BD.

Inj.20FER 4mg IV/OD.

Inj.pan 40mg IV/OD.

Moniter vitals.










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