RT heart failure

CHIEF COMPLAINTS:  A 50 year old man resident of kattangur farmer by occupation came to the casualty with the chief complaint of shortness of breath and decreased urine output since 1 year.

HISTORY OF PRESENTING ILLNESS: My patient was apparently asymptomatic one and half year ago later developed fever for which he went to a local hospital.
 
2 months later he had increasing pedal edema associated with decreased urine output , abdominal distension and SOB grade 2-3, for which dialysis was advised & that was when he came to our hospital.

From the past 5-6 months SOB has been increasing gradually to grade-4 with associated orthopnea & PND.
H/o dry cough present since 7months aggrevated during winter and relieved on medication.
No h/o chest pain/palpitations/chest tightness

No other complaints

PAST HISTORY:

Hypertension since 1 year
 months. 
No h/o DM/ asthma/epilepsy/CAD

PERSONAL HISTORY :
Mixed diet
Disturbed sleep
Decreased appetite
Normal bowel & bladder habits
No addictions

FAMILY HISTORY:
No relevant family history seen .

GENERAL EXAMINATION:
Patient is conscious , coherent and cooperative.
Oriented to time, place and person.
He is moderately built and moderately nourished.

VITALS:
Temperature: afebrile 
Blood pressure: 130/90mm Hg
Resp rate:12 cycles per min 
Pulse rate : 82bpm
Pallor : Present


Icterus : absent
Clubbing: not present
Koilonychia: not present 
Lymphedenopathy: not present 
Edema : present in lower limbs 




GENERAL INSPECTION :
JVP raised 








Scar of failed AV fistula - arterialization of veins 



So they planned dialysis on femoral vein
CVS EXAMINATION:
INSPECTION:
Examination of neck
Carotids : bilaterally visible 
JVP : elevated 
Trachea in the midline
Visible apex beat 




PALPATION:
Trachea midline 
No carotid bruit
thrill present at tricuspid area 
Palpable P2
Apex beat :At left 6th intercostal space lateral to midclavicular line
No suprasternal ,epigastric and Interscapular impulses.

PERCUSSION:
Rt heart border corresponding to rt sternal border
Rt & lt 2nd intercostal spaces are resonant.

AUSCULTATION:
S1 S2 heard 
P2 loud
High pitched grade 4 Pansystolic murmur heard on mitral and tricuspid area.

ABDOMINAL EXAMINATION:
Distended abdomen 
Umbilicus everted
shifting dullness/fluid thrill present



No visible scars/sinuses/pulsations
No tenderness
No organomegaly
Bowel sounds heard 

RESPIRATORY SYSTEM EXAMINATION:
Elliptical & bilaterally symmetrical chest
Both sides moving equally with respiration
Resonant note heard in all areas
Bilateral air entry present
Normal vesicular breath sounds
Fine crepitations heard in right infra axillary & infra scapular areas

CENTRAL NERVOUS SYSTEM EXAMINATION:
Higher mental functions intact
Sensory & motor system normal
Cranial nerves intact
Reflexes present
No focal neurological deficit

LAB INVESTIGATIONS:
Complete blood picture 

HEMOGLOBIN : 7.7g/dl


RENAL FUNCTION TESTS :




RFT interpretation: urea ,creatinine and uric acid levels are elevated .
Random blood sugar are in normal range.


CHEST X RAY:



ULTRASONOGRAPHY ABDOMEN



ELECTROCARDIOGRAPHY:




Left axis deviation and left ventricular hypertrophy are interpreted on ECG.

DIAGNOSIS:   Based on the history,clinical features , examination and laboratory findings my diagnosis is
CHRONIC KIDNEY DISEASE WITH HEART FAILURE.

MEDICATIONS:
7am - T Nicardia 20mg ( nifidipin)
Arkamine 0.1mg (clonidine)
Met XL 50mg ( metoprolol succinate)
Lasix 80mg ( furosemide)
Spironolactone 25mg 

Between 1:30 - 2pm
T Arkamine 0.1mg
Nicardia 20mg

6pm
T Lasix 80mg

8pm
T Arkamine 0.1mg
Met XL 50
Lasix 80mg
Spironolactone 25mg
Nicardia 20mg
Shelcal 500mg ( calcium with vitamin D)

His blood pressure observation after starting medications

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