1702102086 SHORT CASE

A 44 year old male patient has come to the opd with the chief complaints of ,    

  • Bilateral pedal edema since 5 months.
  • shortness of breath since one months.
  • facial puffiness since one month.   

History of present illness :

Patient was apparently  asymptomatic 5 months back and then he developed ,
Bilateral pedal edema since 5 months.
facial puffiness since one month . 

He developed shortness of breath GRADE = 3 to GRADE =4 of( NYHA classification) which was, insidious in onset (ever since he was put on dialysis according to him) and gradually progressing  in nature.

He had Fever yesterday ,which was insidious in onset ,high grade ,on and off in nature and associated with chills and dry cough.

He has pain on the right side of the chest,
Onset - sudden
Duration -since 4-5 days.
Type - pricking 
Aggrevated on sleeping on the side effected, touching the site of pain .
Relieved on sitting position ,not associated with swelling and tenderness.

He had no complaints of: Loss of smell, vomitings , nausea ,chest pain, no decreased urine output.

History of past illness :

Patient underwent 5 sessions of hemodialysis last month and is not on hemodialysis since 8 days.

known case of hypertension since 4-5 years and he is on anti hypertensives, does not take his medications regularly.

Diagnosed with CKD ,1 and half year back and was on medications for 6 months which were stopped later with no valid reason.

He was diagnosed with COVID-19 5 months back ,was on home isolation and tested negative in a week, developed bilateral pedal edema since then.

Not a known case of Diabetes ,asthma ,tuberculosis ,epilepsy ,CVA

Has a history of blood transfusion.

No significant surgical history
No known allergic history

Personal history :

Diet - mixed
Appetite - decreased
sleep - adequate
Bowel and Bladder movements - regular
Addictions - drinks alcohol on a regular basis, decreased since 2 years.
             chews tobacco on a regular basis, decreased since 2 years.

Drug history : 

Nimodipine 10 -20 mg since 1 and half year.

Family history :

No significant family history

General examination :

Patient is conscious ,coherent ,cooperative and was well oriented to time ,place and person 
at the time of examination
He is examined in a well lit room, with consent taken.
He is moderately built and well nourished.
Pallor - present
Icterus - absent
Cyanosis - absent 
Clubbing - absent
lymphadenopathy - absent
Pedal edema - present





Vitals : 

Temperature - 102degrees F
Pulse rate - 105 bpm
Respiratory rate - 40 cpm
Blood pressure - 170/100 mmHg
SpO2 - 85-88% on Room air


Systemic examination :

CVS : S1 and S2 heart sounds heard
      NO murmurs and thrills

RESPIRATORY SYSTEM : Bilateral air entry present                            position of trachea - central
                        Vesicular breathsounds heard
bilateral crackles heard in all the areas

CNS : NFND

ABDOMEN : Soft and non tender
              No palpable masses
              Bowel sounds heard 
              No organomegaly

Investigations :


complete blood picture


Serum electrolytes



Serum creatinine



Blood urea


APTT


Prothrombin time (PT)



Blood grouping 



Serum iron



Random blood sugar


Liver function test


ECG




Ultrasound report




Blood parasites





HIV 1/2 Rapid Test




HBsAg - Rapid




Provisional Diagnosis :

CKD(Chronic kidney disease) on Maintenance hemodialysis.
Anaemia of chronic disease.

Treatment :



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