GENERAL MEDICINE 1601006026 LONG CASE
HALL TICKET NO 1601006026 LONG CASE
A 65 year old male resident of veliminedu, chityal who was maestri by occupation 8 years back, was brought to the hospital on 16th of April, 2021 with chief complaints of swelling in both the legs since 14 days and altered sensorium since 2 days.
History of presenting illness
Patient was apparently asymptomatic 14 days ago when he started developing swelling in both the legs, which was insidious in onset ,gradually progressive, grade 3 pitting edema, aggravated on rest, relieved on walking associated with facial puffiness noticeable on waking up in the morning. History of decreased urine output since 10days. Family members complained of abnormal behaviour since 2days in the form of shouting inappropriately and not allowing to touch him associated with post episodic vomiting.
Not associated with dyspnea, fatigue, palpitations, cough,abdominal pain, abdominal distension
Past history
Similar complaints of pedal edema and decreased urine output were present 5 months ago, then he took medication prescribed by the local doctor furosemide 10mg, only during the episodes of edema and got cured.
History of fall 30years ago is present
Known case of hypertension since 9years, metaprolol,amilodipine since 9years,
Not a known case of tuberculosis, asthma and seizures
Personal history
Diet - Mixed
Appetite- decreased
Bowel and Bladder- bladder movements are altered but bowel movements are regular
Sleep- Adequate
Addictions -None
Family History
Not significant
TREATMENT HISTORY
He's put on dialysis since admission (6 sessions)
Torsemide 10mg since 5months
Metoprolol since 9years
General Examination:
Patient was in altered sensorium while examining
Vitals
Temperature-afebrile
Pulse- 82 beats per minute, regular in rhythm, normal in volume and character. Their is no radio radial and radio femoral delay.
Blood pressure - 110/70mm of hg
Respiratory rate - 16 cycles per min
Pupils- bilateral reacting to light
JVP is normal
PHYSICAL EXAMINATION
Pallor -present
Icterus- absent
Cyanosis - absent
Clubbing- Absent
Edema - Absent
Lymphadenopathy - absent
Central nervous system examination
GCS E4 E4V3M4
Motor system
Rt Lt
Tone UL normal Normal
LL normal Normal
Reflexes Rt Lt
Biceps. 2+ 2+
Supinator 2+ 2+
Triceps 2+. 2+
Knee. 2+. 2+
Ankle. 1+. 1+
Babinski negative Babinski negative
All superficial reflexes are intact
•Sensory & cranial nerves : not able to assess
Per abdomen examination
Scaphoid
Umbilicus midline & inverted
Soft
No organomegaly
No shifting dullness/fluid thrill
Bowel sounds present
Kidneys were not palpable bimanually
CVS examination
S1, S2 heard, no murmurs, apex beat heard at left 5th ICS, medial to MCL
Respiratory system examination
Normal vesicular breath sounds are heard
Bilateral air entry present
Provisional diagnosis
?Renal insufficiency
?Liver failure
? Right heart failure
?DVT
? Lymphedema
Investigations
COMPLETE BLOOD PICTURE
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COMPLETE URINE EXAMINATION
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