1601006192 LONG CASE

 

 HALL TICKET NUMBER : 1601006192

A 34-year-old gentleman, from Motukur, who is a farmer by occupation, came to the hospital on 24/04/2021, for Maintenance Hemodialysis.

History of presenting illness :

• Patient was apparently asymptomatic 3 years back when he was incidentally diagnosed with raised blood pressure of 200/110 mmhg for which he was put on medication.
• Which he took for 4 months but wasnt compliant and stopped taking them thereafter and was asymptomatic for 7 months since then.
• Patient started developing bilateral pedal edema since 13 months, insidious in onset, pitting type, associated with mild facial puffiness and decreased urine output since one year for which he came to the hospital and was put on maintainence dialysis for 10 months.
• Patient complaints of abdominal distension and swelling of legs in between dialysis sessions.
• No h/o burning micturition.
• No h/o blood in urine.

Past history :

• History of HTN since 3 years.
• No history of diabetes , asthma, epilepsy, cardiac disease.

Family history:

• Not significant.
• No h/o HTN, DM, asthma, epilepsy, cardiac disease.

Personal history :

• Diet- Mixed
• Appetite- Decreased
• Sleep- Adequate
• B&B- regular
• No addictions 

General physical examination :

• The patient is conscious, coherent and cooperative.
• He is well oriented to time, place and person.
• He is moderately built and moderately nourished.
• 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.
• There is no Icterus, Clubbing, Cyanosis, Generalised lymphadenopathy.

Vitals :

• Temperature : Afebrile
• Pulse : 80 beats per minute, regular, normal in volume and character. 
• Blood pressure : 140/90 mm of Hg in the left arm.
• Respiratory rate = 20 cycles per minute.
• JVP is elevated to 11.5 mm of H20 at 45 degrees suggesting increased right ventricular pressures. ( probably volume overload due to reduced GFR )

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 :  S1, S2 is heard. No murmurs are heard. JVP is elevated.
• Respiratory system : Bilateral air entry is present, Normal vesicular breath sounds are heard. No adventitious sounds are heard.
• Nervous system : Motor power tone and deep tendon reflexes are intact; sensations are normal. Cranial nerves are intact.

Clinical Pictures :

Elevated JVP 

Pedal edema, pitting type 

[ PITTING PEDAL EDEMA]

Edema seen on hand with AV fistula

[ EDEMA OVER RIGHT UPPER LIMB ]

Abdominal distention due to ascites 

AV fistula / Cimino Fistula 

Investigations :

• Hemogram 
  
  
  
• Complete Urine Examination 
  
  
  
• Renal Function Tests 
  
  
  
• Liver Function Tests 
  

• ECG showing Left Ventricular Hypertrophy (LVH) in leads V1 and V6 
  

Provisional Diagnosis :

Chronic Kidney Disease on Maintenance Hemodialysis (MHD) with secondary Hypertension, with bipedal edema, moderate ascites and anemia.

Treatment :

• Salt restricted diet (<2 gm/day) 
• Fluid restriction (< 1 L/day)
• TAB. FUROSEMIDE 40 mg BD
• TAB. SODIUM BICARBONATE 500 mg BD
• TAB. NIFEDIPINE 10 mg TID
• TAB. CLONIDINE 0.1 mg BD
• TAB. CALCIUM AND VITAMIN D3 SUPPLEMENTS 500 mg OD
• Maintenance Hemodialysis (MHD) 
  
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