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65Y/M WITH SHORTNESS OF BREATH

 This is an online E-log entry blog to discuss and understand the clinical data analysis of a patient, to develop competency in comprehending clinical problems, and providing evidence- based inputs in order to come up with a diagnosis and effective treatment plan to the best of my ability.


A 65 year old male, labourer by occupation, r/o gudigade came with the chief complaint of:

1. Shortness of breath since 3 days


Tha patient was apparently asymptomatic 3 years back when he developed pedal edema uptil the knee, for which he went to the hospital. On performing investigations, he was diagnosed to be hypertensive, and he was told that his kidneys were failing, and dialysis was suggested. 

Following this, they went for a second opinion to Khammam, where the same diagnosis was made. Hence, they came to our hospital to start dialysis.

They had been getting hemodialysis done since 3 years- two times a week. No previous complications had been noted.

Since 4 months, he had left upper limb swelling, which gradually progressive. Additionally, he also developed mild swelling in the chest 4 months ago, which was also gradually progressive.

Since 2 months, he has been having back pain from base of the neck till mid back, which was intermittent in nature. It subsided on taking medication (Tab ultracet)

3 days ago, the patient started having SOB right after his dialysis, while he was still in the hospital. The SOB was grade IV NYHA, with no specific aggravating or relieving factors. Since he was having SOB, the patient decided to stay overnight in the hospital and go back home the next day. However, his condition did not improve and he was hence admitted and put on ventilatory support. The patient additionally complained of chest pain, which was persistent and of dull aching type, with no radiation. 

There was no h/o decreased urine output, orthopnea, PND or palpitations.

The patient stopped working 3 years ago following his CKD diagnosis and decided to stay at home. His wife would go to work instead.



PAST HISTORY

No similar complaints in the past

No h/o DM, asthma, thyroid problems, seizures


PERSONAL HISTORY:-

Diet: Vegetarian since 3 years, after his CKD diagnosis

Appetite: Normal

Sleep: Adequate

Bowel & bladder: Regular

No allergies

Used to drink toddy everyday until 3 years ago


FAMILY HISTORY:

Insignificant 


GENERAL EXAMINATION:

Pt is conscious, coherent, cooperative

Well oriented to time, person, place

Moderately built, well nourished


Pallor +

Pedal edema +

No Icterus/cyanosis/clubbing/Generalized lymphadenopathy


VITALS:

Temp: Afebrile

PR: 83bpm

RR: 18cpm

BP: 110/60 mmHg


General examination on admission:






General examination after 1 week:








Fever chart: 



SYSTEMIC EXAMINATION:

CVS: S1 S2 heard, No murmurs

RS: BAE+, NVBS, no adventitious breath sounds

P/A: soft, non tender 

CNS: NAD, normal higher functions


ECG on admission:

STEMI, LAD blockage noted. (V1,2,3,4)


INVESTIGATIONS on admission 







AFTER 2DAYS:




Ortho cross consultation notes:


Pleural tap was done. 

PLEURAL TAP: 

Pleural fluid LDH 98
Serum LDH 294
Ratio-0.3

Pleural fluid protein-2.0
Serum total protein -5.9
Ratio-0.3

Total count -100cells
Differential count- 
80% lymphocytes
20% neutrophils

Impression: Transudative effusion




CXR BEFORE TAP:




CXR AFTER TAP:



MEDICATION THAT HE IS CURRENTLY ON: 

1. NICARDIPINE, CLONIDINE- HTN



2. ACILET (SODIUM BICARB), CALCITRIOL, FUROSEMIDE: CKD




3. ULTRAKING (PARACETAMOL AND TRAMADOL): ANALGESIA



PROVISIONAL DIAGNOSIS:

K/C/O CKD on MHD, HTN

Lateral wall MI

?Spondylodiscitis

?Left Upper Limb lymphedema (secondary to AV fistula surgery)


TREATMENT PLAN:

-T Lasix 40mg/PO/BD

-T Nicardia 10mg/PO/TID

-Inj EPO 4000IU once weekly

-Inj Iron sucrose 100mg in 100ml once weekly

-T MVT PO/OD

-T NODOSIS 500mg PO/OD

-T OrofexXT OD

- T BioD3 OD

-T Dolo 650 SOS

-T Ultracet BD






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