42/M with SOB,pedal edema,vomitings and decreased appetite

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A 42 year old male,daily wage worker by occupation came to the OPD with

CHIEF COMPLAINTS:

Bilateral pedal edema since 15 days.

Decreased appetite since 15 days.

Vomitings since 15 days.

Shortness of breath since 5 days.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 15 days back,then he had complaints of decreased appetite and vomitings,insidious in onset,non bilious,non projectile ,containing food particles.

He also has a history of bilateral pedal edema,pitting in type,insidious in onset,gradually progressive,not associated with any postural variations,no aggravating and relieving factors.

He has a history of shortness of breath(grade 4 MMRC),insidious in onset,gradually progressive(grade 2 MMRC),not associated with any postural variations,no aggravating or relieving factors.

History of watering right eye since 10 days,for which he was initially prescribed eye drops in a hospital in chotuppal.His condition has now progressed to complete vision loss and restricted eye movements in the right eye.

History of vesicles on upper part of nose on right side since 4 days which is insidious in onset and progressed to crusting and initially appeared to not be spreading and is not itching in nature.The vesicles seem to have spread to the left side of the neck which are of the same nature as that of the previous lesions.

History of bleeding from nose,which occurred following nose picking and resolved spontaneously.

No history of chest pain,palpitations,syncopal attacks,paroxysmal nocturnal dyspnea and Orthopnea.

No history of cold,cough and fevers.

HISTORY OF PAST ILLNESS:

Known case of Hypertension,since 1 year,6 months.On tab.Telmasartan 40 mg.

History of Chronic Kidney Disease since 1 year,on dialysis for maintainence.

History of similar complaints 1 year and 6 months,Shortness of breath and bilateral pedal edema,which was treated at a educational government hospital.Symptoms got relieved after consulting and taking medications and undergoing a session of dialysis.The patient had a history of fever following the session of dialysis,for which he consulted our hospital and got treated.

He was adherent to his medications for 2 months and then became non-adherent to medications after his symptoms got relieved and he started feeling better.

He has a history of trauma accident due to falling off from a significant height,6 years ago,following high he fractured his left lower limb bones.He did not take any pain medications for long term post the accident.

He had an active playtime and good appetite during childhood and did not have a history of recurrent infections or health complaints.

PERSONEL HISTORY:

Diet-Mixed

Appetite-Decreased

Sleep-Adequate

Bowel-Regular

Bladder-Regular

Addictions-Alcohol(stopped since 1 year 6 months)

Whiskey-90 mL everyday,since 22 years.

DAILY ROUTINE:

The patient wakes up everyday at 6 AM,eats breakfast which is rice and a vegetable curry and goes to work at 7AM.

He eats lunch at 1 PM,at home,rice and vegetables.

He rests for some time after lunch and goes back to work.

He comes back from work by 6 PM and rests for some time and then drinks 90mL-180mL whiskey everyday and then eats dinner around 9 PM and then goes to sleep.

FAMILY HISTORY:

No significant family history.

TREATMENT HISTORY:

Telmasartan 40 mg

Feraden-XT+(ferrous ascorbate,folic acid,zinc sulphate)

Nodosis(Sodium Bicarbonate)

Nicardia(Nifedipine)

Calvic D(Calcium and Vitamin D3 tablet)

Lasix(furosemide)

ALLERGIC HISTORY:

No allergies to any kind of food and medications.

GENERAL EXAMINATION:

Patient is conscious, coherent, and cooperative

Moderately built and moderately nourished.

No pallor

No icterus

No cyanosis

No clubbing

No lymphadenopathy

Pitting edema seen in both lower limbs extending till the knees.

VITALS:

Temperature - Afebrile

Pulse Rate - 102 bpm

Respiratory Rate - 15cpm

Blood Pressure - 150/90mmg

Sp02 -

GRBS - 99mg/dL

CVS EXAMINATION :

INSPECTION:

shape of chest is normal
jugular venous pulse is not seen(because of central venous line for dialysis)
no precordial bulge is seen

apical impulse is not well appreciated

PALPATION:

Apex beat is shifted to 6th intercoastal space,lateral to mid clavicular line.
no parasternal heaves
no thrills
no dilated veins

PERCUSSION:

left heart border is not confined to normal limits.
right heart border is with in confined limits

AUSCULTATION:

mitral area, tricuspid area, pulmonary area, aortic area - S1,S2 heard

no additional sounds are heard

RESPIRATORY SYSTEM:

INSPECTION:

Bilateral Air entry Present

Chest is symmetrical

Trachea is midline

No retractions

No kyphoscoliosis

No Winging of scapula

No Scars, sinuses, Dilated Veins

All areas move equally and symmetrically with respiration

PALPATION:

Trachea - Midline

Chest is bilaterally symmetrical and elliptical

Percussion Right                   Left
Supra clavicular: resonant resonant
Infra clavicular:          resonant resonant
Mammary: resonant Resonant
Axillary: resonant resonant
Infra axillary: resonant resonant
Supra scapular: resonant            resonant
Infra scapular: resonant resonant
Inter scapular: resonant resonant

Auscultation:              Right.                   Left

Supra clavicular:.       NVBS                NVBS
Infra clavicular:          NVBS                NVBS
Mammary: NVBS NVBS
Axillary: NVBS NVBS
Infra axillary: NVBS NVBS
Supra scapular:   NVBS NVBS
Infra scapular: NVBS NVBS
Inter scapular: NVBS NVBS

PERABDOMEN:

INSPECTION

Abdomen is not distended.

Umbilicus is central in position.

PALPATION -

No Tenderness on superficial palpation.

No local rise in temperature

Liver is Non Tender and not palpable

Spleen is Not palpable

PERCUSSION:Fluid thrill absent

AUSCULTATION- Bowel Sounds Heard

CENTRAL NERVOUS SYSTEM EXAMINATION:

HIGHER MENTAL FUNCTIONS:

Conscious

Well Orientation to time, place and person

Speech and language – normal

Memory – immediate-retention and recall, recent and remote are present
No delusions, hallucinations
No Emotional lability

2.CRANIAL NERVES -RIGHT/LEFT

1::

Sense of smell-present/present

2::

Visual acuity- (-)/(6/60)

Confrontation test-abnormal/normal

3/4/6::

Extraocular movements-absent/present

Direct light reflex-absent/present

Indirect light reflex-absent/present

5::

Sensory-present/present

Motor-present/present

Reflex-

Corneal-present/present

Conjunctival-present/present

7::

Sensory-

Taste of anterior two thirds of tongue-present/present

Sensation over Tragus-present/present

Reflex-

Corneal-present/present

Conjunctival-present/present

Secretomotor-

Normal/Normal

Motor-

Slight deviation of angle of mouth and loss of nasolabial fold on right side/normal on left side

8::

Rinne’s-positive/positive

Webers-not lateralised/not lateralised

Nystagmus-absent/absent

9,10::

Uvula/palatial arches-symmetrical and centrally placed.

Gag reflex-present/present

Palatal reflex-present/present

11::

Trapezius-good/good

Sternocleidomastoid-good/good

12::

Tongue protrusion to the midline and either side-normal/normal

SUPERFICIAL REFLEXES
A.Corneal reflex                                 Present on both sides
B.Conjunctival reflex                         Present on both sides.
C.Abdominal reflex                           Present
D.Plantar reflex                                  Present

SENSORY SYSTEM - Normal

TEST	RIGHT	LEFT
I – SPINOTHALAMIC 1. Crude touch 2. Pain 3. Temperature II – POSTERIOR COLUMN 1. Fine touch 2. Vibration 3. Position sense 4. Romberg’s sign III – CORTICAL 1. Two point discrimination 2. Tactile localisation 3. Graphaesthesia 4. Stereognosis	Normal Normal Normal Normal Normal Normal Absent Normal Normal Normal Normal	Normal Normal Normal Normal Normal Normal Absent Normal Normal Normal Normal