A 32 year old male patient had come with complaints of pedal edema , shortness of breath and low urine output

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.                                                                                                                                                  A 32 year old male patient had come with complaints of pedal edema , shortness of breath and low urine output 

C/C : 


- pedal edema 

 -shortness of breath 

-reduced urine output since 10 days 


History of present illness : 

The patient was asymptomatic one year ago and developed diminision of vision consulted doctor and was diagnosed with hypertension for which he has been using Tab.Arkamin and Tab.Telma H since 1 year.He was referred to another hospital where he had gotten a creatinine test done and the level was 8.6 and he was started on Arkamin.

He was referred to KIMS for dialysis and had been getting dialysis done since the past 8 months 


He developed pitting type of edema below the knee since one month, weakness and backache since one month which relieved on rest.


He has decreased urine output and consumes alcohol [180ml] rarely.                                              On 18th September 2021 , 


The patient was refferd to orthopaedic department as patient complained of neck pain 


- Tenderness noted at L4, L5 region 


-no neurological deficits noticed 


-no local raise of temperature 

History of past illness : 

Known case of HTN since 1 year (on Tab.Arkamin , Tab Terma H)

Not a known case of DM,CAD,Asthma,TB,Epilepsy



PERSONAL HISTORY : 


Occupation. : Auto driver 

Diet – Mixed

Appetite – Normal 

Bowels – Regular

Micturition – decreased urine output


Has no known allergies 


Drinks alcohol rarely[180ml]


Family h/o : 

His brother is a k/c/o HTN 

GENERAL EXAMINATION : 


Patient was conscious,coherent,cooperative and examined in a well lit room.


VITALS


 Pulse rate : 99 bpm


Respiratory rate : 19/min


BP : 150/80mmHg


Temperature : Afebrile


GRBS : 127mg%


SpO2: 98% at room air


PHYSICAL EXAMINATION


 Pallor – absent


Icterus – absent


Cyanosis – absent


Clubbing of fingers/toes – absent


Lymphadenopathy – absent 



Edema of feet – present,below the knee, pitting type


Malnutrition – absent 





Systemic examination: 


CARDIOVASCULAR SYSTEM


S1 and S2 heard


No thrills


No cardiac murmurs




RESPIRATORY SYSTEM


Vesicular breath sounds heard


Trachea is in central position


No wheezing


No Dyspnoea 

On 8th october JVP was seen prominently and Rhonchi was heard , the patient was put on nebulization with budecort .


 ABDOMEN : 


Obese shaped abdomen


No tenderness


No palpable mass


No hernial orifices


No free fluid


Liver and spleen not palpable


Bowels sounds are heard


CNS : 


Conscious and normal speech


Normal gait


Cranial nerves normal


Sensory system normal


Motor system normal




REFLEXES




              RIGHT LEFT




 Biceps +2 +2




Triceps +2 +2     Supinator +2 +2




Knee +2 +2




Ankle +2 +2 


INVESTIGATIONS ORDERED : 

On 2 sept 

USG 



USG 


On 4/9/21 : 


Grade II FATTY LIVER 


B/L GRADE II RPD


On 5/9/21 : 





On 18/9/21 


MRI images on 18/9/21 

MRI report : 



On 29/9/21 : .





On 5 th October : 


The reports were : 




Colour Doppler : on 5/10/21




Repeat Doppler on 6/10/21






Ecg : 

On 5/10/21

on 6/10/21 : 
Pleural tap for right lung .

ECG : 


On 7/10/21 



Fever chart : 

Updated fever chart : 


Culture and sensitivity report : 


Clinical images : 

On 9/10/21




On 10/10/21 



On 13/10/21 

On 14/10/21 








PROVISIONAL DIAGNOSIS


CKD on MHD secondary to Hypertensive nephropathy


Diagnosis : 


UTI , HFpEF ( EF 55%) ,DCMP + with  Transudative pleural effusion 

L3,L4 spondylodiscitis 

With CKD on MHD 

With hypertensive retinopathy

K/c/o HTN since 1 1/2 year 



PLAN OF MANAGEMENT: 


  Renal Transplantion


TREATMENT : 

On 5/10/21 : 

Fluid restriction <1L/day

Salt restriction <2.4L/day

T.Lasix 40mg PO/BD

T.Nicardia 20mg PO/TID

T.Arkamine 0.1 mg PO/BD

T.Shelcal CT po/od 

T.Nodosis 500 mg 

T.Met XL 50 mg po/od 

INJ erythropoietin 4000 units weekly once 

BP monitering 


On 6/10/21 : 

Fluid restriction <1L/day


Salt restriction <2.4L/day


T.Lasix 40mg PO/BD


T.Nicardia 20mg PO/TID


T.Arkamine 0.1 mg PO/BD


T.Shelcal CT po/od 


T.Nodosis 500 mg 


T.Met XL 50 mg po/od 


INJ erythropoietin 4000 units weekly once 


BP monitering 


On 7/10/21 

Fluid restriction <1L/day


Salt restriction <2.4L/day


T.Lasix 40mg PO/BD


T.Nicardia 20mg PO/TID


T.Arkamine 0.1 mg PO/BD


T.Shelcal CT po/od 


T.Nodosis 500 mg 


T.Met XL 50 mg po/od 

T.Metolazol 5 mg po/ bd 


INJ iron sucrose 100 mg iv / bd 

INJ erythropoietin 4000 units weekly once 


On 14/7/21 

Fluid restriction < 1. 5 L / day 

Salt restriction < 2g / day 

INJ piptaz 2.25 mg IV /TID 

INJ pan 40 MG iv /od 

INJ lasic 40 MG iv /tid 

Tab nicardia 20 mg po/od 

Tab met xl 50 mg /po/od 

Tab hydralazine 12.5 mg po /qid 

INJ erythropoietin 4000 iu / sc weekly 

T nodosil 500 mg /po/bd 

T orofer XT po/bd 

INJ iron sucrose 100 mg in 100 ml NS / weekly 

Tab ZOFER 4 MG po/tid 


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