57 yr old male with shortness of breath and decreased urine output

 A 57 year old male, resident of Nakrekal, mason by occupation came to hospital with chief complaints of 

 shortness of breath since 1 week

Decreased urine output since 1 week

HISTORY OF PRESENT ILLNESS

patient was apparently asymptomatic 1 week back then he had shortness of breath while walking upstairs and walking at normal pace (grade 2) which gradually progressed to shortness of breath at rest in last 1 week ( grade 4). Shortness of breath aggravate by doing work and on lying horizontally on bed. Relieved by taking rest in reclined position

There is history of gradual decreased urine output since 1 week which is not associated with increased frequency, urgency or incontinence

No H/O fever, chronic cough, weight loss, hemoptysis, sputum

No H/O chest pain, sweating, palpitations, syncope 

No H/O burning micturition, difficulty in micturition

PAST HISTORY

No similar complaints in past

History of pedal edema on and off since 1 year, present upto level of ankle

He is a known case of hypertension since 1 year and he takes telmesartan 40mg every day morning after breakfast 

No H/O diabetes, asthma, tuberculosis, epilepsy

PERSONAL HISTORY

diet: mixed 

Appetite: normal

Sleep: adequate

Bowel and bladder: regular

Addictions: he used to drink 90 ml alcohol and smoke 5 to 6 BD’s regularly since last 30 to 35 years. Since last 1 year he only drink and smoke occationally

FAMILY HISTORY

No similar complaints in family 

TREATMENT HISTORY

Since last 4 years he is taking analgesics for knee pains. He took them occasionally in the beginning , but since last 2 years he took them daily or on alternate days.

Since last 1 year he is taking telmesartan 40 mg every day morning for hypertension

GENERAL EXAMINATION 

pallor -ve

Icterus -ve

Clubbing -ve

Cyanosis -ve

Lymphadenopathy -ve

Generalised edema -ve

VITALS

Temperature: afebrile

Pulse rate: 90 bpm

Respiratory rate: 18 cpm

Blood pressure: 130/80 mm hg 

GRBS : 124 mg/dl

SpO2 : 92 %

SYSTEMIC EXAMINATION

Respiratory system

Inspection: 

Upper respiratory tract: no halitosis, oral thrush, tonsillitis, deviated nasal septum, turbinate hypertrophy, nasal polyp

Lower respiratory tract:

chest is bilaterally symmetrical

Trachea is in midline

Moving symmetrically with inspiration and expiration

No drooping of shoulders, supraclavicular and infraclavicular hollowing, intercostal fullness, retractions, indrawings, crowding of ribs

There is a scar of approximately 2 to 3 cm on the right side of front of the chest. Similarly — Lesions are present on the back of the chest

Palpation:

Trachea is central on palpation

No intercostal widening/crowding, subcutaneous emphysema, intercostal tenderness

Apical impulse is  felt in 6th intercostal space lateral to mid clavicular line

Chest movements are bilaterally symmetrical

Chest measurements:

Tactile vocal fremitus      Right                 Left

Supraclavicular                Resonant          Resonant

Infraclavicular                  Resonant         Resonant

Mammary                          Resonant         Resonant

Inframammary             Resonant         Resonant

Axillary.                             Resonant         Resonant

Infraaxillary                 Resonant         Resonant

Suprascapular               Resonant         Resonant

Infrascapular                Resonant         Resonant

Interscapular                  Resonant         Resonant

No local rise in temperature and no tenderness

Percussion:

                                  Right                     left

Supraclavicular                Resonant          Resonant

Infraclavicular                  Resonant         Resonant

Mammary                          Resonant         Resonant

Inframammary             Resonant         Resonant

Axillary.                             Resonant         Resonant

Infraaxillary                 Resonant         Resonant

Suprascapular               Resonant         Resonant

Infrascapular                Resonant         Resonant

Interscapular                Resonant         Resonant

No percussion tenderness

Auscultation:

Normal vesicular breath sounds are heard

Crepts  are heard in right and left infra axillary and infrascapular areas

Wheeze is audible in right and left inframammary area

CVS

Inspection: 

Chest wall is normal in shape and is bilaterally symmetrical

Apex beat appears to be present at 6th intercostal space lateral to mid clavicular line

No precordial bulge, kyphoscoliosis

No visible veins and sinuses

Palpation: 

Apical impulse is felt at 6th intercostal space lateral to mid clavicular line

All peripheral pulses are felt and compared with opposite side

No parasternal heaves, precordial thrills

Percussion:

Left heart border is shifted laterally, and right heart border is present retrosternally

Auscultation:

Mitral, tricuspid, pulmonary, aortic and Erb’s area auscultated

S1 S2 are heard, no abnormal heart sounds

CNS

Higher mental functions are intact

Cranial nerve functions are intact on right and left sides

Motor system: bulk and tone are normal

 Power is 4/5 in all 4 limbs

Deep tendon reflexes are present and normal

Superficial reflexes are present and normal

No involuntary movements

No signs of cerebellum dysfunction

No neck stiffness, kernigs  and Brudzinski’s signs are negative

ABDOMINAL EXAMINATION

Inspection:

Abdomen is flat and flanks are free

Umbilicus is inverted

No visible scars, sinuses, dilated veins, visible pulsation

Hernial orifices are normal

Palpation:

No local rise of temperature

No tenderness and enlargement of Liver, spleen, kidney 

Percussion:

No fluid thrill

Liver span is normal, no spleenomegaly

Auscultation:

Bowel sounds are heard 

Provisional diagnosis: heart failure with hypertension

INVESTIGATIONS

                                           16/03/23

Hemoglobin:               8.1Gm/dl

Total count:                    12680 cells/Cumm

Neutrophils:                   74%

Lymphocytes:                12%

Eosinophils:                   00%

Monocytes:                    14%

Basophils:                00%

PCV:                              25 vol%

MCV:                                89.6fl

MCH:                          23.0pg

MCHC:                            32.4%

RBC count:                     2.79 million/cumm

Platelet count:               2.16 lakhs/cumm

Smear: normocytic normochromic, no hemoparasites

RFT                         16/03/23

Urea:                       118 mg/dl

Creatinine:             5.3 mg/dl

Potassium:             3.2 mEq/l

Uric acid:               7.6 mg/dl

Calcium:                10 mg/dl

Phosphorus:         6.9 mg/dl

Sodium:                  143 mEq/dl

Chloride:                 98 mEq/dl

LFT:                      13/03/23

Total bilirubin:   0.77 mg/dl

Direct bilirubin: 0.20 mg/dl

AST:                      24 IU/L

ALT:                      11 IU/L

ALP:                      312 IU/L

Total protein:      6.2 Gm/dl

Albumin:              3.04 Gm/dl

A/G ratio:            0.96

ABG        17/03/23

Ph:             7.43

PCO2:       31.6 mm Hg

PO2:          64 mmHg

HCO3:       21.1 mol/L

Serology: negative for HIV & HbsAg

Ultrasound

Right kidney: 7.5*4.5 cm

Left kidney: 7.5*4.2 cm

Both kidneys: decreased size and increased echogenicity.

                          Corticomedullary differentiation is lost

                                                                    2d echo

DIAGNOSIS

Heart failure with reduced ejection fraction

Chronic kidney disease on maintenance dialysis

TREATMENT

 Inj. Thiamine 100mg IV/TID

 Inj. Lasix 40 mg/IV/BD

 Inj. Erythropoietin 4000 IU/SC/ once weekly

 Inj, PAN 40mg/IV/OD

Tab. Nicardia retard 10 mg/RT/BD

Tab. Metoprolol 12.5 mg/RT/OD 

Tab. Nodosis 500 mg/RT/BD

Nebulisation with duolin 8th hrly & budecort 12th hrly 

Intermittent CPAP

regular monitoring of vitals