55 year old man with SOB

 Medical case discussion 

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        CASE DISCUSSION

A 55 year old male, a resident of nalgonda, who is a farmer by occupation came for follow up dialysis with chief complaints of SOB since 10 days

• HOPI : 

Patient was apparently asymptomatic 20 years then had muscle cramps , increased frequency of urination, giddiness for which he went to hospital and was diagnosed with DM type II and is on medication (T.Glymiperide + Metformin) since then.

1 year back he had generalized weakness , polydipsia,polyurea, dizziness, visited hospital and was found to have uncontrolled DM 2 and is on insulin ( since then.

6 months back he was taken to hospital after experiencing palpitations , dizziness , blurring of vision , involuntary movements involving upper limbs & body and was diagnosed with hypertension & Renal failure.

H/o SOB since 6 months NYHA 1-2 and from last 1 month he developed sudden onset shortness of breath NYHA 3-4 , gradually progressive , orthopnea present, PND present

Low backache since 1 month 

No h/o fever, Chest pain, Palpitations, Syncope

Decreased Urine output since 1 month , thin stream , poor flow , increased frequency , hesitancy , Burning micturition present.

One episode of vomiting yesterday night 

•Past History : 

K/c/o DM-type II since 20 years 

K/c/o hypertension since 6 months

No history of asthma,TB, epilepsy, thyroid abnormalities

 • History of dialysis 

  1st - 31st may 2023 

  2nd - 2nd June 2023

  3rd - 5th June 2023 

  4th - 8th June 2023

•PERSONAL HISTORY: 

Diet: Mixed

Appetite: Normal

Sleep: Disturbed ( PND +) , nocturia was present until 1 month back 

Bowel: Regular

Bladder: Decreased urination.

Habits: Does not consume any form of alcohol or tobacco.

●FAMILY HISTORY: 

Not significant

●DRUG HISTORY:

HAI & NPH 3 units (three times a day) Insulin for the past 1 year , previously was on glimi-metformin 2

TELMA for hypertension since the past 6 months

●DAILY ROUTINE:

Until an year ago he worked as a farmer. Now he wakes up at 5 am. he takes his  breakfast at 7 am. Then does some household work, self chores . He then has lunch at 1 pm. Dinner at 8 pm and goes to bed at 9 pm. Nocturia previously up until 2 months ago (3 to 4 times)

●GENERAL EXAMINATION:

The patient was examined in a well lit room after obtaining consent.

The patient was conscious, coherent and cooperative. He was moderately built and moderately nourished.Pallor: Absent

Icterus: Absent

Cyanosis: Absent

Clubbing: Absent

Lymphedenopathy : Absent

Edema: Absent 

Dry scaly patches over skin 

Vitals : 

Temperature - Afebrile

BP - 130/80 mm Hg

Pulse - 78 BPM

RR - 25 CPM

Rbs - 124 @ 7pm

●SYSTEMIC EXAMINATION:

Cardiovascular system:

•Inspection:

Appears normal

Pericardium is normal

Apex beat not visible

Thrills absent

No scars, sinuses, dilated veins 

No precordial bulge is seen.

•Palpation:

All inspectory findings are confirmed

Trachea is central 

Apex beat 6th intercostal space 1cm lateral to mid clavicular line.

•Auscultation:

S1 and S2 heard.

No murmurs heard

Respiratory system:

•Inspection

Shape of chest is elliptical and bilaterally symmetrical.

Trachea appears to be central

No scars , sinuses, engorged veins.

Symmetrical expansion of chest

•Palpation:

All inspectory findings are confirmed

Trachea appears to be central

Tactile vocal fremitus normal

•Percussion:

Resonant note is heard in all areas

•Auscultation :

Normal vesicular breath sounds are heard.

No adventitious breath sounds heard.

ABDOMEN:

Abdomen is Normal

Moves symmetrically with respiration

Umbilicus is central and inverted

No scars or sinuses

No local rise in temperature

No organomegaly

CNS:

Higher mental functions normal.

Cerebellar functions normal.

Cranial nerve examination normal.

Sensory examination: normal.

Motor examination:

Power: upper limbs: 5 bilaterally

              Lower limbs: 4 + bilaterally.

Tone: Normal

Reflexes:        R           L

Biceps:           2          2

Triceps:          2           2

Knee:              2           2

Ankle:             2           2

Provisional diagnosis:

Acute on chronic LVF

Chronic renal failure since 6 months

K/c/o DM-type II for 20 years

K/c/o hypertension for 6 months

●Investigations : 

X-Ray chest 

Interpretation : 

Cardiomegaly

Mild Hazziness in the right and left lower lobes

Blood Investigations : 

Urea               - 119mg/dl

Creatinine     - 7.9mg/dl

Uric acid        - 7.7mg/dl

Potassium     - 4.7 mg /dl 

Alkaline phosphatase - 200IU/L

Total Proteins               - 5.8 gm/dl

Albumin                        - 3.14 gm/dl

Hb - 8.2 gm/dl

PCV - 23.9 vol%

MCV 79.1 FL

RBC count - 3millions/ cumm

RBS - 467mg/dl

CUE

ECG

Sinus Tachycardia

Heart rate : 100

USG Abdomen :

Bilateral Grade 2 RPD changes

Left Renal cortical cyst 

Left Renal calculus

• Final Diagnosis: 

Heart failure 

Chronic kidney disease on Maintenance Hemodialysis

K/c/o DM-type II for 20 years

K/c/o hypertension for 6 months

• Treatment :

Fluid restriction <2L /day

Salt restriction <2g /day

INJ HAI & NPH 3Units

Tab Lasix 40 mg BD

Tab Nicardia 20 mg PO/TID

Tab Arkmain 0.1mg PO/TID

Tab Orofer -XT PO/OD

Hemodialysis