A 55 YR OLD MALE WITH SHORTNESS OF BREATH , PEDAL OEDEMA AND FACIAL PUFFINESS

Meghana 

Roll.no :161 ( 9th semester )

DATE :-12/12/2021

Introduction :

"This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs .This e-log book also reflects my patient centered  online learning portfolio and your valuable comments on comment box is welcome".

CASE PRESENTATION  :-

A male patient aged 55 yr old came to the  medicine OPD with 

Chief complaints : 

1) Shortness of breath since 3 months 

2) pedal oedema and facial puffiness since 2 months 

History of presenting illness :

Patient was apparently asymptomatic 3 months back then he developed cough ( intermittent ) , occasionally wet cough 

Not associated with blood vomiting , fever or burning micturition

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3 months back he developed shortness of breath while doing work ( granite cutting ) 

It is aggravated by doing work , and is not relieved with medication

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He also developed pedal oedema ( pitting oedema) 3  months back 

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15 days later he developed facial puffiness , he visited local pharmacy and used medicines(?) given by the pharmacist for 2months ,symptoms relieved on medication 

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H/O diarrhoea since 3 months 

H/O pain in left abdomen ( throbbing type ) , pain is moderate 

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H/O drowsiness , anorexia and generalised weaknesS

No H/O nausea, vomiting or pruritis

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1 month back he visited an mbbs doctor and and found his creatinine levels to be elevated , and ultra sound scan revealed features suggestive of Polycystic Kidney Disease , he was referred to our hospital 

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He was admitted to our hospital on 21 st Nov 2021 , his serum creatinine was 6.8 mg/ dl at the time of admission .

He underwent dialysis 4 times in our hospital 

Past History  :

Trauma to right eye by a stone 2 yrs back which resulted in loss of vision in the right eye 

HTN - yes ( recently diagnosed ) 

No H/O DM, Asthma, TB , Epilepsy, CAD.   

No H/O recent infection , drug abuse or poisoning 

Personal History :

• Diet - mixed 
• Appetite - normal 
• Sleep - adequate
• Bowel movements - increased 
• Bladder movements - normal 
• Addictions - BD ( 1 pack ) / day since 30 yrs , occasional consumes alcohol 

Family History : no similar complaints in family members 

General Examination :- 

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

He is moderately built and nourised 

VITALS: Temperature - afebrile 

Pulse rate : 72bpm

Resp.rate :20/min 

BP -140/70 mm of Hg 

SpO2 - 99 % 

 Physical Examination :Pallor - present 

Icterus - absent 

Clubbing - absent 

Cyanosis - absent 

Lymphadenopathy - No 

Oedema - pedal oedema ( pitting type )  

Systemic Examination :- 

CVS : S1 and S2 heard , no thrills or murmurs heard 

Respiratory system : BAE + 

Normal vesicular breath sounds - heard 

Trachea - central in position 

No wheezing , no dyspnoea 

Per abdominal examination:-

Soft , non tender , no evidence of organomegaly 

No palpable masses or free fluid seen 

Bowel sounds heard 

CNS examination : NAD 

Investigations :- 

On 20/11/21, 

ultrasound scan :- 

features suggestive of Polycystic Kidney diease 

Blood grouping ( 20/11/21):

LFT (20/11/21) :

 RFT (20/11/21):-

Random blood sugar : (20/11/21)

Serum Iron : (20/11/21)

Hemogram (20/11/21)

HIV test (20/11/21)

HbsAg (20/11/21) 

Anti Hcv (20/11/21)

SARS COV-2 test ( 20/11/21)

ECG (21/11/21)

2D Echo (22/11/21)

complete urine examination (24/11/21)

PATIENT CLINICAL IMAGES : 

Insertion of catheter at internal jugular vein for hemodialysis : 

Provisional diagnosis :- Chronic Kidney Disease secondary to Polycystic Kidney Disease 

Management :- Renal Replacement therapy 

Treatment :- 

On 21/11/21 

• Fluid and salt restriction 
• Tab NICARDIA (20 mg) BD 
• Tab NODOSIS ( 500 mg ) BD 
• Inj Erythropoietin 4000 IU weekly once 
• Tab SHELCAL PO OD 

ON 22/11/21 

• Fluid and salt restriction 
• Tab NICARDIA (20 mg) BD 
• Tab NODOSIS ( 500 mg ) BD 
• Inj Erythropoietin 4000 IU weekly once 
• Tab SHELCAL PO OD 

On 23/11/21 .

• Fluid and salt restriction 
• Tab NICARDIA (20 mg) BD 
• Tab NODOSIS ( 500 mg ) BD 
• Inj Erythropoietin 4000 IU weekly once 
• Tab SHELCAL PO OD 

On 24/11/21 

• Fluid and salt restriction 
• Tab NICARDIA (20 mg) BD 
• Tab NODOSIS ( 500 mg ) BD 
• Inj Erythropoietin 4000 IU weekly once 
• Tab SHELCAL PO OD 
• Inj THIAMINE NS 100 mg in ml IV TID