Case 08

24  Nov 2021

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A 60 year old male came to OPD with chief complaints of

         

• Pedal edema since 4days    
• Shortness of breath since 4days       
• Decreased urine output since 4days

HISTORY OF PRESENT ILLNESS:

Patient was a farmer by occupation. He used to wake up early at 5 in the morning,  had breakfast ( rice curry) , reach the farm by 9'0 clock  , working till 2'O in afternoon, had lunch ( rice curry)  and completing the work and reaching home by 9  followed by dinner ( curd rice) 
Patient was apparently asymptomatic since 5 yrs, 

One fine day, as he was heading to farm, suddenly he felt giddiness and was rushed to local hospital. He was diagnosed with hypertension. He was on medication for hypertension since then.  

3 years back, he started experiencing shortness of breath ( Grade 2 )  and was unable to work due to which he stopped going to farm .

patient complains of cough since 2yrs. But it was productive since 4 days. On examination, sputum is white in colour with no blood and foul swelling.

 1 year back, patient complains of shortness of breath which progresses from Grade 2 to grade 3 along with swellings of lower limb. He went to Hyderabad where he underwent 1 session of dialysis and was later referred to KIMS.  He undergone 6 sessions of dialysis. He was relieved on medication but he still complains of shortness of breath ( grade 2) 

Since 4 days, patient complains of swelling of lower limb and face . He also complains of decreased urine output with shortness of breath when lying down.

There is no symptoms of fever, palpitations, chest pain and burning micturition.

PAST HISTORY: 

Patient is known case of hypertension since 5yrs , bronchial Asthma and abdominal distension since 2yrs.

Not a known case of DM, COPD.

PERSONAL HISTORY

Appetite: loss of appetite

 Diet: mixed

Bowel movements: constipation since 4days

Bladder: decreased urine output since 4 days 

Sleep: disturbed since 2 days due to increase in cough during night 

Allergies: patient is not allergic to known drug 

Addictions:

Alcohol consumption: he consumes alcohol during festivals (90ml) but has stopped since 3 years. 

GENERAL EXAMINATION:

The  patient is conscious, coherent and uncooperative and well oriented to time, place and person.

He is moderately built and  nourished. 

Patient complaints of pedal edema. It is pitting in nature Pallor is present 

No signs of  icterus, cyanosis, clubbing, generalized  lymphadenopathy. 

                                          

Vitals:

Temp-98.4 degrees F

BP-110/70mm hg

PR-68bpm

RR-16cpm

Spo2: 75% on room air

Respiratory system examination: 

Bilateral air entry is normal. Wheeze is noticed in all areas. 

Decreased breath sounds are heard in both right and left  infrascapular areas and left infra axillary area.

 

CVS: 

Apex beat was localised in the 4th intercostal space 1 cm medial to mid clavicular line. 

S1 and S2 are heard.  NO murmurs

No abnormal heart sounds were heard .

JVP is raised.

       

CNS:

• Patient is conscious
• Speech is normal
• Reflexes are normal
• There is no functional deficits

Per abdominal examination: 

• Abdomen is tense and distended.
• Shifting dullness is noticed. 
• No organomegaly was noticed. 
• Free fluid is present.

PROVISIONAL DIAGNOSIS:

   

CHRONIC RENAL FAILURE

Investigations:

ECG:

USG ABDOMEN:

COMPLETE BLOOD PICTURE:

FINAL DIAGNOSIS:

CHRONIC RENAL FAILURE WITH HYPERTENSION WITH  MODERATE ASCITES And  BRONCHIAL ASTHMA.

TREATMENT:

23  Nov 2021

1. NODOSIS

2. Inj Lasix 40mg

3.shelcal OD

4. Orofer BD

5. Erythropoietin weekly once

6. Neb with BUODECORT 2 respules

7. Duolin 1 respule

8. Inj. Hydrocort 100mg

24  Nov 2021

1. fluid restriction < 1 litre/ day

2. Salt restriction < 4grms per day

3. AUGMENTIN 625mg

4. NODOSIS 500mg OD

5. syrup. GRILLINCTUS BM 10ML

6. o2 inhalation 

7. Inj Lasix 40mg

8.shelcal OD

9.Orofer BD

10.Erythropoietin weekly once

 25  Nov 2021

1. fluid restriction < 1 litre/ day
2. Salt restriction < 4grms per day
3. AUGMENTIN 625mg
4. NODOSIS 500mg OD
5.  syrup. GRILLINCTUS BM 10ML
6. o2 inhalation 
7. Inj Lasix 40mg
8. shelcal OD
9. Orofer BD
10. Erythropoietin weekly once
11. Tab DYTOR 
12.  INJ HYDROCORT
13. Neb with BUDECORT  1 respules.

   26  Nov 2021

1. fluid restriction < 1 litre/ day
2. Salt restriction < 4grms per day
3. AUGMENTIN 625mg
4. NODOSIS 500mg OD
5. syrup. GRILLINCTUS BM 10ML
6.  o2 inhalation 
7.  Inj Lasix 40mg
8. shelcal OD
9. Orofer BD
10. Erythropoietin weekly once
11. Tab DYTOR 
12. INJ HYDROCORT
13. Neb with BUDECORT  1 respules.

26  Nov 2021

 Patient was discharged on this medication 

1. Fluid restriction  < 2l per day

2. salt restriction < 1.5 grm per day

3. TAB NODOSIS

4. TAB OROFER

5. TAB SHELCAL

6. INJ ERTHROMYCIN 4000 IU / SC

7. syrup ASCORTIN TID 

   15ml once

8. NEB with BUDECORT and DUOLIN 8TH hourly.

9. Tab ALDECTONE 50mg OD

10. TAB lasix 40mg BD

FOLLOW UP :

Asked to come after 4days.