1601006161 SHORT CASE
SHORT CASE : A 34-YEAR-OLD GENTLEMAN WITH CHRONIC KIDNEY DISEASE UNDERGOING DIALYSIS
HALL TICKET NUMBER : 1601006161
A 34-year-old gentleman, from Motukur, who is a labourer by occupation, came to the hospital on 17/04/2021, for Maintenance Hemodialysis.
History of presenting illness :
- The patient was apparently asymptomatic 3 years ago, when he was diagnosed with Hypertension, secondary to Chronic Kidney Disease.
- He was regularly taking his medication for Hypertension, until he abruptly stopped doing so 2 months ago.
- The patient has been undergoing maintenance hemodialysis at our hospital since the past 10 months.
- He complains of facial puffiness, abdominal distension and swelling in the legs.
- The patient also complains of loss of weight over the past 3 years. Initially, he was 63 kg, now he is 52 kg.
General Physical Examination :
- The patient is conscious, coherent and cooperative, lying supine on the bed
- He is well oriented to time, place and person.
- He is moderately built and moderately nourished.
- On head-to-toe examination :
- There is presence of Pallor in the lower palpebral conjunctiva.
- There is evidence of :
- Facial and periorbital puffiness
- Bipedal edema which is of pitting type
- Moderate ascites - Shifting dullness is present.
- There are small, dark brown spots of hyperpigmentation visible on the palms
- There is no Icterus, Clubbing, Cyanosis, Generalized lymphadenopathy.
Vitals :
- Temperature = afebrile
- Pulse = 80 beats per minute, regular, normal in volume and character. There is no radio-radial or radio-femoral delay. The condition of the arterial wall is normal.
- Blood pressure = 140/90 mm of Hg in the left arm in supine position.
- Respiratory rate = 16 cycles per minute.
- JVP is elevated to 11.5 mm of H20 at 45 degrees.
Per Abdominal Examination :
- On Inspection : The abdomen is mildly distended.
- On palpation : The abdomen is soft and non-tender.
- Shifting dullness is present.
- Fluid thrill is absent.
- Suggestive of Moderate ascites.
Examination of other systems :
- Cardiovascular system : Hyperdynamic apex is seen. S1, S2 is heard. No murmurs are heard.
- Respiratory system : Bilateral air entry is present, Normal vesicular breath sounds are heard. No adventitious sounds are heard.
- Nervous system : Motor and Sensory systems are normal. Cranial nerves are intact.
PROVISIONAL DIAGNOSIS :
Chronic Kidney Disease on Maintenance Hemodialysis (MHD) with secondary Hypertension, with bipedal edema, moderate ascites and anemia.
Clinical Images :
Investigations :
- Hemogram
- Complete Urine Examination
- Renal Function Tests
- Liver Function Tests
- Ultrasonography of the abdomen
- ECG showing Left Ventricular Hypertrophy (LVH) in leads V1 and V6
Treatment :
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