34 YEAR OLD MALE WITH SOB SINCE 4 MONTHS

 THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 

CHIEF COMPLAINTS:

A 34 year old male came to opd with SOB since 4 months

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 2 years ago then he developed giddiness for which he went to local hospital where he diagnosed with hypertension.Where the doctor prescribed anti hypertensives but he didnt continue the medicine and took only when he had neck pain

Fatigue,Mild shortness of breath and chest pain started 3months back(which is not associated with cough) for which he went to local hospital where patient was started on clinidipine .

since then complaints were on and off but didnot subside

SOB worsened since one month to grade 4,associated with mild bilateral pedal edema ,non pitting up to knees

H/O fever 20 days back,associated with cough and weight loss 

patient came to our hospital with grade 4 and got admitted

PAST HISTORY:

No similar complaints before 2years

he got epilepsy at the age of 3 yrs due to fever

No significant medical or surgical history

Not a known case of DM,CAD,bronchial asthma

FAMILY HISTORY:

No family history of HTN,DM, bronchial asthma,epilepsy

ADDICTIONS:

Patient is a chronic alcoholic and chronic smoker since 15 years

Alcohol 90-150ml per day whiskey/brandy

1-2 beedi per day for 15 yrs

He also chews gutka from 15 years

GENERAL EXAMINATION :

Patient is conscious ,coherent,cooperative,oriented to time ,place,person

pallor present

no signs of icterus,lymphadenopathy.

mild pedal edema present in both legs 

vitals : temp-98.3f

bp-190/120 mmof hg

RR:20 cpm

PR:85 bpm

SYSTEMIC EXAMINATION:

CVS-S1 and s2 heard

parasternal heave present

diffuse apex beat 

Raised JVP ,no thrills,no tender points

dull note in 5,6,7 intercoastal spaces in infra axillary line

RESPIRATORY SYSTEM:

BAE +,normal vesicular breath sounds heard

PER ABDOMEN:

Soft,non tender,no organomegaly

CNS:

Conscious

sensory system: intact

motor system:reflexes normal

power of upperlimb and lowerlimb 5/5

INVESTIGATIONS:

BGT-A positive

HB-7G/DL

NA+-136 meq/l( normal 135 -145 meq/l)

k+-4.9 meq/l(normal value 3.5 -5 meq/l)

cl- -107meq/l(96-106 meq/l normal)

serum creatinine -4.3mg/dl(normal range 0.6 to 1. mg/dl)

LFT :

TB- 0.95

DB-0.20

AST-30

ALT-17

ALP-108

TP-5.0

ALBUMIN-1.4

ALBUMIN/GLOBULIN ratio -0.24

blood urea-115mg/dl

ECG shows left ventricular hypertrophy

 

CXR:

FUNDOSCOPY(23/2/22):

Right eye- grade 1hypertnesive retinopathy

left eye-grade 2 hypertensive retinopathy

RENAL ARTERY DOPPLER:

Bilateral grade 3 renal parenchymal disease

raised AT value suggestive of chronic renal parenchymal disease

ULTRASOUND ABDOMEN AND PELVIS (24/2/22):

mild ascites with mild to moderate pleural effusion

B/L grade 3 renal parenchymal disease

2D ECHO: ALL CHAMBERS DILATED

ABG:

PROVISIONAL DIAGNOSIS:

chronic renal failure secondary to hypertension

TREATMENT:

T.NICARDIA 10mg SOS

STRICT BP MONITORING HOURLY

T.ULTRACET 1/2 TAB SOS 

FLUID AND SALT RESTRICTION