45 year old male with history of Pedal oedema and Shortness of breath



CASE :

 45 year old male , lorry driver by profession , resident of Nalgonda came with chief complaints of Shortness of breath since 4 months

HOPI :

Patient daily routine includes , he used to drive lorry across the states - work for 5-6 days a week from the age of 20 yrs.

Until 4 months back he was living happily with his family but 4 months back everything started to go wrong when he was not able to do his work of earning.

He was apparently asymptomatic 4 months ago then he developed shortness of breath grade - 3 insidious in onset , progressive ,relieved on taking medication and rest . associated with orthopnea.

He was taken to a local hospital and dialysis was initiated.

History of Pedal oedema after a week , pitting type upto knees was seen .

Dialysis was done since 4 months , twice weekly

History of Dry cough since 15 days , sudden in onset 7-10 episodes in a day and each episode consisting of 8-10 bouts of cough .

Oliguria since 1 week

No history of fever, burning micturition , frothy urine , hematuria

No history of chest pain , palpitations , syncopal attacks


PAST HISTORY :

Known case of hypertension since 4 months

No history of DM , Asthma , TB , Epilepsy , CAD , CVA

FAMILY HISTORY :

Not significant 

PERSONAL HISTORY :

Diet : mixed

Appetite : normal

Bowel and bladder movements : regular

Sleep : adequate

Addictions : Alcohol occasional 

GENERAL EXAMINATION :

The patient was conscious, coherent , cooperative and well oriented to time place and person

Pallor - present 

Icterus - absent

Cyanosis - absent

Clubbing - absent

Koilonychia - absent

Lymphadenopathy - absent

Oedema - bilateral pedal oedema present

Jugular venous pressure - raised

VITALS : 

Temperature : afebrile

Pulse rate : 68 BPM

Respiratory rate : 18 CPM

BP : 150/90 mmhg

GRBS : 102 mg/dl

ON SYSTEMIC EXAMINATION :

CVS :

INSPECTION :

Chest is bilaterally symmetrical 

No precordial bulge

Apex impulse visible in 6th intercoastal space lateral to midclavicular line

No visible sinus , scars and dilated veins

PALPATION :

Apex impulse felt in 6th intercoastal space , 1 cm later to midclavicular line 

No palpable thrills

AUSCULTATION :

S1 and S2 heard , no murmurs


RESPIRATORY SYSTEM :

INSPECTION :

Chest is elliptical and bilaterally symmetrical

Trachea appears to be central

Movements appears to be equal on both sides

No scars , sinuses and visible pulsations

PALPATION :

No local rise of temperature

No tenderness

Trachea is central , movements equal on both sides

PERCUSSION : 

Resonant nodes were heard in all areas

AUSCULTATION :

Bilateral air entry is present

Normal vesicular breath sounds heard

Bilateral infra-axillary, infra-scapular crepts +


ABDOMEN :

Shape of abdomen : obese

No scars and sinuses seen

No palpable mass

No free fluid

Liver - not palpable

Spleen - not palpable


CNS :

Patient is conscious

Speech is normal

No signs of meningeal irritation 

Sensory and Motor system - normal

Gait - normal


PROVISIONAL DIAGNOSIS :

Heart failure - CCF with EF 40%

K/c/o CKD on MHD since 4 months

K/c/o HTN since 4 months


INVESTIGATIONS :















USG abdomen:
Normal sized kidneys, Grade III RPD +
Minimal ascites +





2D ECHO:
Dilated LV/LA/RA/RV
Mild - Moderate LV dysfunction EF 40%
Mild MR+
Diastolic Dysfunction +


TREATMENT :

Tab NIFIDIPINE 5 mg  PO/BD

Tab LASIX 40 mg PO/BD

Hemodialysis - twice weekly



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