Age : 72

Sex : Male

Address : Jalan Laut, Muar

Occupation : Retired lorry driver


CHIEF COMPLAINTS

Profuse diarrhea for past 3 months

Dizziness and generalized weakness for 8 days


HISTORY OF PRESENTING ILLNESS

      The diarrhea was acute in onset, watery and foul smelling. He claims to have had up to 20 bouts per day. He is currently using adult diapers. However it has progressively reduced in frequency and he has not had any attacks in the past 2 days, however there was no bowel movement either.


      Patient felt dizzy while sitting at home in the evening. It was sudden in onset. During the attac, he claims that everything around him is spinning and eventually becomes dark. The whole episode lasts for a few minutes. The attacks started in1995 and has been continuing since. He says that the frequency of the attacks have been increasing since. He lies down for 15 to 20 minutes to get relief from the dizziness. He says that after getting up everything is back to normal and that he will be profusely sweating. In previous episodes of the same nature, he claims to have sustained cuts on his forehead because he hit his head against the window while falling down.


      He also suffers from weakness, whereby he claims that he is unable to get up after defaecation in a squatting toilet. He finds it hard to stand up because there is nothing for him to hold on to while getting up, as a result he fell in the ward toilet 3 times in the past few days. The weakness has been increasing since the past 10 yaers, when he was diagnosed with renal disease. weakness has been associated with mild breathlessness which has been worsening an currently is of grade 2. He says that he has been mainly home bound for the past 10 years, he becomes tired even by moving around the house. He was forced to retire due to his condition.


      Patient has been admitted numerous times for the same complaint in the past. He s says that he is given a blood transfusion each time.


PAST  HISTORY

      He was diagnosed with renal disease in 1995 where he went to a doctor after noticing frothy urine and suffering an attack of dizziness at his workplace, he experienced this arter he had finished loading up his lorry.


      He was also told that he had hypertension, afterwhich he was referred to the hospital.


      He continued to suffer from attacks of dizziness, initially twice a month and it had been increasing in frequency up to now.


      He suffered a severe bout of edema in 1995. It started bilaterally on both legs, and advanced up to the thighs, abdomen, upper limbs and face. It lasted for a few months. It was resolved by medication.

 


      He started hemodialysys in January 1996 in melakafor 3 months, Bachang for 2 ½ months, and in Sungai Bong for 5 yars. He began hemodialysis in Muar hospital on 31-3-2001 and has been going there since. Currently he undergoes 3 sessions of hemodialysis a week.


       He also claims to have had a massive attack of hemetemesis 2 years ago for which he neede 21 pints of blood to be stabilized. He was later told that it was caused bby a perforation in the gastrointestinal tract.


FAMILY HISTORY

      There is no history of renal disease and hypertension in the family. His parents passed away due to old age. 


PERSONAL HISTORY

      Sleep has been disturbed throughout his admission, he sometimes requires sleeping tablets to help him sleep. He consumes a mixed diet. There has been no bladder movement for the past 10 years. He has had daiarhhea for the pasrt 3 months, before which he had normal bowel activity. He has been smoking for the past 35 years, about 10 to 15 sticks a day., however he has stopped for 10 years now.


SOCIAL HISTORY

       He lives about 20 minute away from the hospital. He lives with his wife. he has 3 children who are supporting him financially. His house is a single storey house.
 
 
 
 
 
 
 
 
 
 
 
 


General physical examination.


      Patient is well built but poorly nourished. He is poorly hydrated, his skin is dry and flaky.

      There is an swelling in the anterior aspect of the neck suggestive of a thyroid swelling. 


There is no pallor, no icterus, no cyanosis, no clubbing of the fingers, however there transverse ridges on fingernails of both hands. There is no lymphadenopathy and no pedal edema.


Pulse: 67 beats per minute, regular rhythm, and of normal volume.

BP : 130/87 mmHg taken on left arm in supine position.


There are 2 swellings approximately the size of an egg on the midline and upper 1/3 rd of the lateral aspect of the right forearm suggestive of an AV fistula for hemodialysis.


LOCAL EXAMINATION

CVS

Inspection

Chest is symmetrical, no precordial bulge, no scars or sinuses

Apex beat is visible 


Palpation

Apex beat felt at the 6th intercostals space 2 cm lateral to midclavicular line.


Percussion

Vertical border extends to the 6th intercostals space


Auscultation

S1 and S2 heard in mitral and tricuspid area only.

Mid diastolic murmur was heard in the mitral area.


ABDOMEN

Inspection

Abdomen is scaphoid in shape. Flanks are empty. No visible pulsations. No scars or sinuses.


Palpation

There is no local rise in temperature.

No tenderness, no guarding and rigidity


Percussion

Liver border was felt 5 cm below the costal margin