39 M with shortness of breath and Generalised body swelling
39 M with shortness of breath and Generalised body swelling
A 39 year old male presented with chief complaints of
Shortness of breath since since 6 months
Generalised body swelling since 6 months
Decreased urine output since 6 months.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 3 and half years back ,
then the patient had an episode of giddiness ?due to shock (from the death of his brother in law) ,for which he went to a local hospital and got diagnosed with hypertension.
Since then the patient was started on increasing doses of Telma and later Telma -H, but the patient was not compliant to the medication. He used to take the medication only when there's occasional neck stiffness and pain.
History of mild shortness of breath and chest pain 2 years back, which is not associated with cough or fatigue for which he went to a local hospital where he was told to have uncontrolled blood pressure and patient was started on cilnidipine.
Since then complaints were decreased in frequency but did not subsided.
Shortness of breath worsened 18 months back from exertion to even at less than ordinary activity ( NYHA Grade 2 to 3 which is associated with bilateral pedal edema, pitting type, upto the knees.
H/o fever 16 months back, associated with cough and weight loss (patient's waist size reduces from 32 to 28 in the span of 1 month) relieved with medication sputum was negative for cbnaat.
In February 2022 patient presented to our hospital with complaints of worsened shortness of breath even at rest, Diagnosed to have Acute pulmonary edema secondary to heart failure and Renal Failure and treated conservatively with Diuretics and Anti hypertensives. Symptoms relieved and patient discharged with online follow up.
8 months back in view of refractory pulmonary edema and metabolic acidosis patient was initiated on hemodialysis and continuing maintainance hemodialysis regularly with frequency of 2-3 times per week.
Current admission :
Patient presented with Shortness of breath at rest and intermittent generalised body swelling and distension of abdomen since 6 months
Fever since 1 month
Shorteness of breath initially on exertion which gradually worsened to shortness of breath at rest associated with distension of abdomen.
Fever which is high grade, intermittent type associated with chills not associated with nausea, vomiting, altrered sensorium, cough and burning micturation.
personal psychosocial history:-
37 yrs old male elder son of his family who studied till 9th standard later he discontinued because of financial issues there after he started his own business at the age of 12yrs( paper recycling) runned for about 3yrs and discontinued because of loss in his business and returned to his grown up place there after for about 1-2yrs he went for farming with his parents and later because in need of more money he started working as lorry cleaner( as he do overnight work and feel tired he started getting habituated to drink alcohol and smoking)in the gap of 2 yrs he learned how to drive and he continued as lorry driver( he returns to home once in a week, used to continuously drink alcohol more than a full bottle with dec intake of food, in between a week too she used to drink).After 8yrs (2014) he got married later after this children were born he discontinued as lorry driver and started working as daily labourer where he used to lift heavy weights after doing work to overcome his tiredness he used to drink alcohol (180ml/day). one fine day (in the year of 2020) he went to his sister house(family gathering),there was an incident of sudden death of his brother in law he became very anxious( as his sister lost his husband in young age) and weak when he got his first bp check ( 190/110) he was prescribed anti htn but he refused to take it regularly( as there is a misnom in his village not to take antihtn in a very young age) and to overcome his sorrowness he started taking much more alcohol and smoking very regularly.
All his present complaints started since the month of November (2021) where he first noticed pedal edema and sob on exertion
Psychological illness in current admission :
Since 6 months patient has family disputes with wife and mother in regards to his health, addictions ( tobacoo chewing )
4 months back in a huge argument among the couple , his wife left him alone and reached her maternal home along with there children. Since then he couldn't sleep at night even he doesnt feel breathless.
On further enquiry He emotionally broke down and remembered sleepless nights he spent in memories of his children. Since then he was emotionally upset which hampered self care and stopped taking Tab. Telma 40 mg and Met XL 50 mg ( both due to ignorance and financial issues ). Increased water intake with altrered food habbits.
Problems to be addressed
1. Depression
2. Tobacco deaddiction
PAST HISTORY:
No similar complaints in the past.
No significant medical or surgical history
Not a known case of DM, bronchial asthma, CAD, Epilepsy
FAMILY HISTORY:
No family history of HTN, DM, bronchial asthma, epilepsy
PERSONAL HISTORY :
Sleep disturbances since 6 months
Appetite improved since dialysis but decreased since distension of abdomen
Decreased urine output and no constipation.
Patient is a chronic alcoholic and chronic smoker since 15 years
Alcohol 90-150 ml per day whiskey/brandy
1-2 beedi per day for 15 years
Tobacco chewing daily Since 15 years
Examination :
Patient is conscious, coherent, cooperative well oriented to time place and person.
Thin built and moderately nourished.
Vitals :
Bp 140/70 mmhg
HR 110 bpm
Temp 103.5F
RR 24-26 cpm
Positive findings :
General examination
Temporal wasting
Prominent superficial temporal vessels
Pallor
Dry and Bald tounge
Mild Pectus excavatum ( false finding may be due to grossly distended abdomen )
Bilateral pedal edema
Systemic examination :
Cardiovascular system :
Raised JVP seen above the angle of mandible in sitting position
Diffuse visible precordial pulsations
Diffuse Apex beat with lateral most palpable at left 6th intercostal space lateral to mid clavicular line
Parasternal heave present
Palpable P2 present
Pansystolic murmur present best heard at apex and radiating to left axilla
Grade 4/6
Per Abd examination :
Grossly distended abdomen
Fullness of flanks
Umbilicus everted
Subcutaneous soft swellings consistent with lipoma
Tenderness present at needle insertion site ( last paracentesis 3 days back )
No organomegaly
Fluid thrill present
Respiratory system :
Bilateral air entry present, crepitations in bilateral infra axillary area.
Central nervous system :
No focal neurological deficits.
INVESTIGATIONS :
Hemogram :
Haemoglobin: 5.1gm/dl
Total count:6,200 cells/cu mm
Neutrophils: 80
Lymphocytes: 10
Eosinophils:02
Monocytes:08
Basophils:00
PCV:16.1
MCV:85.2
MCH:26.9
MCHC:31.6
RDW CV:15.6
RDW SD:47.7
RBC count:1.89
Platelet count: 1.2 lakh
RBC:microcytic hypochromic few pencil cells
WBC:within normal limits
Platelets:count decrease on smear
No hemo parasites seen
Impression: microcytic hypochromic anemia with thrombocytopenia
2D Echo
Right atrium dilated,Right ventricle dilated,left atrium dilated,left ventricle dilated,concentric LVH+
ESD:4.74
EDD:6.58
DPW:1.38
EF:52%
FS:26%
IVS:1.38
Aorta:3.85
Pulmonary artery:Dilated
Pericardium:minimal PE(+)
IVS size(2.27cms)
Mitral flow:E>A
Aortic flow:1.69
Pulmonary flow:1.10
Tricuspid valve:Rvsp=70+10=80mmhg
Severe TR with PAH:moderate to severe AR/MR
Global hypokinesia,no as/ms
Fair LV function
No diastolic dysfunction,no LV clot
RFT :
Urea:72
Creatinine:7.3
Uric acid:6.0
Calcium:9.6
Phosphorus: 4.4
Sodium:143
Potassium: 4.3
Chloride: 101
LFT :
Total Bilirubin:0.87
Direct Bilirubin:0.17
SGOT:17
SGPT:20
Alkaline phosphate:132
Total proteins:6.0
Albumin:2.7
A/G Ratio:0.85
USG Abdomen :
Liver- Normal size and echogenic
Spleen-10cm Normal size and echogenic
Rt kidney-7.5×3.1cm
Lt Kidney-7.6×3.2cm
CMD lost
U.bladder minimally distended
No lymphadenopathy
Gross Ascites
Impression:B/L Grade 2-3 RPD changes
Gross Ascitis
Serum iron:79
RBS:85
Ascitic fluid Analysis :
Sugar:104
Protein:3.0
Ascitic Fluid Amylase:36.1
Ascitic fluid for ldh:110
SAAG
Serum Albumin:2.7
Ascitic Albumin:1.54
SAAG:1.75
LDH:215.7
HIV1/2 Rapid test Non reactive
HBsAg-RAPID is Negative
Anti HCV Antibodies :Non reactive
Problem representation
39M with Chronic kidney disease with Heart failure and pyrexia.
Problems to be tackled
Ascites
Shortness of breath
Fever
Anasarca
