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Here we discuss our individual patient’s problems through series of inputs from the global online community of experts with an aim to solve those patient’s clinical problems with collective current best evidence-based inputs.
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CHIEF COMPLAINT : 40 y/o male swelling of feet and difficulty in breathing since 3 days.
PRESENT HISTORY : Pt was apparently alright 3 days ago
He had swelling of the feet which was insidious on onset, did not subside with rest.
Accompanied by insidious onset shortness of breath which is present even at rest because of which pt is confined to the bed.
No H/o fever / evening rise in temperature
No h/o weight loss
No h/o night time breathlessness / increased difficulty with lying supine / chest pain
PAST HISTORY :
K/c/o HTN since 2 years
K/c/o Calcemic Uremic Arteriolopathy
Has been on maintenance hemodialysis since 2 years every once in 2 weeks
GENERAL EXAMINATION
Pt is conscious, coherent, cooperative ; oriented to time place and person
Moderately built and moderately nourished
Pallor present
Icterus, Cyanosis, Lymphadenopathy
B/L Pitting Pedal Edema up till ankle joint lasts around 1 minute
No visible pulsations on the neck
Vitals
- Afebrile
- Pulse - 72 bpm
- Resp rate - 16 cycles per min
- BP - 140/100 mm hg
CVS -
Apex at 5th ICS
S1 S2 heard
No murmurs
Respiratory -
B/L air entry present
Trachea central
Vocal fremitus resonant and symmetrical
Vesicular breath sounds
Gastro-Intestinal
Scaphoid, soft non tender abdomen
Hernial orifices normal
No organomegaly
Bowel sounds heard
CNS
Conscious
HMF normal
Motor and Sensory systems Normal
Provisional Diagnosis -
40 y/o pt k/c/o HTN on biweekly dialysis with CUA with B/L Pedal Edema and Grade IV SOB
Investigations
1. Hemogram
2. RFT
3. LFT
4. Serology - HI, HbsAg, HCV
5. Chest x-ray
6. USG Abdomen
7. ECG
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