N. Geetha. 54

January 17 2022
58 year old male, labourer by occupation, came to the OPD with the chief complaints of Shortness of breath since 30 days, worsened 1 day back, chest pain since 30 days ,facial puffiness since 30 days

History of Presenting illness - 
Patient was apparently asymptomatic 4 years ago

4 years ago - pt complained of giddiness, went to a local hospital and was diagnosed as Hypertensive, on regular medication since then T. Nicardia 10mg, T. Arkamine 0.1mg sos

2 years back Pt developed B/L pedal edema, progressed gradually to knees, diagnosed with renal failure and initiated dialysis weekly twice

Left upper limb swelling, gradually progressing to current size, since 4 months .
Also developed rt upper limb swelling since 4 days.
 Swelling in the left chest region, gradually progressing to current size, since 4 months
Back pain since 2 months, subsided on medication (T. Ultracet)

30 days back - developed
Shortness of breath ,

Grade II-III progressed to Grade IV since 30 days along with orthopnea .
Sob worsened 1day back, associated with dragging type of chest pain .came for dialysis last night.
Even after dialysis, chestpain did not subside
Ecg was done(18/01/22): ST elevations noted in V2,V3,V4


Repeat ecg done (on 19/01/22): 
ST elevations subsisded

C/o. generalized body pains
No c/o palpitations, giddiness, cold, cough, burning micturition


PAST HISTORY -

Known case of Hypertension since 4years on Tab nicardia 20mg OD
Not K/C/O TB, Epilepsy, Asthma, CAD.

Personal history:
Appetite- normal
Diet- mixed
Bowel movement- Regular
Alcoholic stopped 4 yrs ago
Non smoker
On examination:

Pt is C/c/c

No Pallor,Icterus,Cyanosis, clubbing,Lymphadenopathy

B/L pedal Edema(pitting type) present









Vitals
Pr:94bpm
Bp:120/80
Spo2:97% at RA
Temp - Afebrile




Systemic examination

CVS - S1,S2 +
RS - BAE + 
CNS - NAD
P/A- Soft, non tender

Investigations on 02/01/2022:




Repeat x-ray



Serology - Negative
Ortho referral for back pain :


Investigations on 08/01/2022:

Serology: negative
Rft:
lft:

Ecg:


Xray on 21/01/2022:

Diagnostic pleural tap was done.

Post -pleural tap xray

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

Transudative effusion


Ortho referral done



Provisional Diagnosis -
CKD on MHD
Heart failure secondary to coronary artery disease(recent lateral wall MI)
?Spondylodiscitis
Hypertensive since 4yrs
?left upper limb lymphedema (secondary to AV fistula surgery)



Treatment-
Fluid restriction (<1l/day)

Salt restriction (<2g/day)

T· LASIX 40 mg PO BD

T. Nicardia 20mg PO BD

T. ULTRACET 1/2 tab QID

T. OROFER-XR PO OD

T. SHELCAL-CT PO OD

T.SORBITE 5 mg PO/BD

T.CLOPITAB-A 75 mg OD






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