1601006099 SHORT CASE

 SHORT CASE: 1601006099 

A 35-year old gentleman who is a farmer by occupation, resident of Miryalaguda,  came to the hospital with: 

Chief complaints of swelling in both the legs since 13 months.

History of presenting illness:

Patient was apparently asymptomatic 3 years back when he was incidentally diagnosed with raised blood pressure of 200/110mm Hg for which he was put on medication which he took for 4 months but wasn’t compliant and thereafter completely stopped taking them. 

Patient started developing bilateral pedal edema since 13 months, insidious in onset, pitting type, extending up until the knee, associated with mild facial puffiness and decreased urine output since one year for which he came to the hospital and was put on maintainence hemodialysis for 10 months now.

Patient complains of abdominal distension and swelling of legs in between dialysis sessions. 

No history of blood in urine

No history of burning micturition

No history of nocturia

No history of pruritis 

No history of fatigue, drowsiness

No history of altered sensorium

Past history:

Patient is a known case of hypertension since 3 years. 

No history of diabetes mellitus, bronchial asthma, cardiac diseases, epilepsy.

No past surgical history. 

Family history:

No similar complaints in family. 

No history of diabetes, hypertension, asthma, cardiovascular conditions 

Personal history:

Mixed diet; decreased appetite; sleep is adequate 

Bowel and bladder habits are normal 

Occasional alcoholic; not a smoker; no addictions 

General Examination:

Patient is conscious, coherent, cooperative, moderately built and moderately nourished.

Pallor present, evident in lower palpebral conjunctiva and pale tongue

Pedal edema present, pitting type

No icterus, no cyanosis, no clubbing, no koilonychia, no generalised lymphadenopathy, facial and periorbital puffiness seen. 

Vitals: pulse taken in sitting position, left radial pulse; pulse rate : 90 bpm

BP: 140/90 mm Hg measured in sitting position on left upper arm

Respiratory rate: 20 cpm

Elevated jvp at 45 degrees

Afebrile

Abdominal examination:

Inspection: Abdomen is mildly distended. 

Palpation: soft and non tender

Shifting dullness is present

Fluid thrill is absent

Suggestive of moderate ascites

Bowel sounds heard

CVS examination: S1, S2 heard, no murmurs, Hyperdynamic apex is seen ,no palpable thrills. 

CNS examination:

Higher mental functions intact.

Patient was alert and conscious.

No signs of meningeal irritation, normal gait and speech. 

Pupils equal and reactive to light.

Reflexes: Superficial and deep tendon reflexes are intact

Investigations: 

The following tests have been done.

1. Complete blood picture

2. Urinalysis

 

3. Renal function tests

 

4. Liver function tests

5. Blood sugar, serum potassium 

6. Chest x ray, ecg 

7. Ultra sound abdomen

Provisional diagnosis: Chronic kidney disease with secondary hypertension with bipedal edema, 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)