SHORT CASE 2

 

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65 year old male patient r/o Nakrekal presented to casualty with complaints of 

C/O Shortness of breath grade 3 since 4 months .

C/O B/L pedal edema since 4 months .

C/O abdominal distension since 5 days

C/O Oliguria since 2 days

HISTORY OF PRESENTING ILLNESS : 

Patient is toddy climber by occupation , was apparently asymptomatic 4 months ago . 

-Intially he noticed b/l swelling of lower limbs , gradual onset and progressive . Pitting type and extending upto knees .

Associated with shortness of breath grade 2 , progressed to grade 3 over 4 months .

H/O orthopnea and PND present .

No h/o chest pain , palpitations 

In view of sob , patient visited local hospital and was told ,he had a stone in one of his kidneys and both his kidneys failed .

He was advised maintainace hemodialysis,but patient denied and was discharged on medications .

His pedal edema subsided after using medications .

He continued taking medications , but noticed loss of appetite, weight , fatigue and generalized weakness .

His urine output was adequate previously . H/o hematuria present occasionally

No h/o pus in urine , burning micturition , frothy urine .

As he had generalized fatigue ,loss of appetite and ,sob ,elevated urea and s. creatinine he visited our hospital and was initiated on hemodialysis by placing central venous catheter in right internal jugular vein .

Patient had 4 sessions of hemodialysis .

He went to Hyderabad and got A-V fistula on his left hand .

C/o Low back ache and body pains .

C/O abdominal distension since 5 days , sudden onset and progressed gradually . Associated with increased sob on lying down and abdominal tightness.

Pedal edema is mild extending upto ankle joint.

No h/o yellowish discoloration of eyes . No h/o binge alcohol intake .

Past history - K/c/o HTN since 10 years and is not on regular medication .

NOT a k/c/o DM, TB , ASTHMA,CAD , EPILEPSY,CVA .

No surgical history and past Medical history

No h/ o NSAID abuse .

Personal history - Regular bowel and bladder movements 

Adequate sleep 

Loss of appetite present 

Mixed diet 

Social & Educational History : 

Married for 27 years with 2 children. Not educated 

Family history - Not significant 

Addictions - Toddy drinker occasionally -3 times /week . 90 ml 

Non -Smoker 

PROVISIONAL DIAGNOSIS :

65 year old male with acute history of oliguria and abdominal distension ,on a background of Sob and pedal edema and HTN 

?Acute decompensated Heart failure in view of anasarca and orthopnea and PND .

? Renal failure in view of decreased urine output and Anasarca and h/o renal calculi and HTN 

General examination : 

Pt C/C/C

Pallor - present

No icterus , clubbing, cyanosis,koilonychia , lymphadenopathy 

B/L pedal edema - pitting type present. extending upto ankle .

Jvp - couldn't be assessed due to central line .

Skin - Dry ,scaly , itching present .

Eyes - Grade 2 HTN retinopathy changes noted on fundoscopy .

Vitals : 

Bp - 140/90 mmhg - Right arm supine posture

Pulse - 130 bpm ,regular ,normal volume, condition of vessel wall - normal, no radio-radial or radio-femoral delay.

Resp rate - 26/ min

Spo2 - 97% on RA 

Grbs - 110 mg/dl 

Temp -99 F 

SYSTEMIC EXAMINATION : 

GIT EXAMINATION : 

INSPECTION : 

Shape of abdomen - Distended-uniform 

Flanks – Full

Umbilicus – Everted 

Skin – Stretched, shiny 

No scars, sinuses, striae, nodules , discoloration.

Dilated veins – on front present

Movements of the abdominal wall - All quadrants equally moving with respiration .

Abdomino - Thoracic type of breathing

NO visible intestinal peristalsis

Hernial Orifices normal 

 Cough impulse - Negative 

External genitalia - Scrotal swelling present 

PALPATION : 

Measurements - Abdominal Girth - 108 cm  

Flanks - full 

Superficial Palpation – Tenderness present in epigastrium 

No local rise of temperature 

Direction of Blood Flow in Veins - away from umbilicus 

Deep Palpation :

Liver Span - Couldn't be palpalted due to gross distension .

Spleen - Couldn't be palpalted due to gross distension 

Kidney - Couldn't be palpalted due to gross distension 

Any other Palpable swelling - No

Hernial Orifices - normal

Murphy’s Punch/Renal angle tenderness - no tenderness

External Genitalia - scrotal edema present . non tender and trans -luminant 

PERCUSSION:

Fluid Thrill - Present 

Shifting dullness - Present 

AUSCULTATION:

Bowel sounds – Present 

Aortic, Renal Bruit - Absent 

CARDIOVASCULAR EXAMINATION : 

INSPECTION:

Chest wall shape - Ellipsoid and b/l symmetrical

No Precordial bulge, Pectus carinatum/excavatum

No Kyphoscoliosis

No Dilated veins, scars, sinuses

Apical impulse - Visible in left 5 ICS 1 cm lateral to MCL .

Pulsations – epigastric, parasternal - absent 

PALPATION:

 

Apical impulse – Tapping type , felt in left 5 ICS 1 cm lateral to MCL .

Pulsations – No Epigastric pulsations 

            Parasternal Heave – Present - Grade 2

          No Thrills and palpable heart sounds .

Auscultation : 

S1 S2 heard in Aortic , pulmonary,tricuspid and mitral areas .

No added sounds 

No murmurs 

Respiratory system -B/L NVBS 

 B/L fine crepitations present IAA ,ISA . 

CNS - NO abnormality detected .

INVESTIGATIONS : 

BGT:- A positive

Serum iron :- 83 

CBP : 

HB - 7 g/dl 

TLC - 12,400 cells /mm3

Platelets -1.3 lakhs .

RFT:- 

Urea :- 92 mg/dl

Creatinine :- 5.7 mg/dl

Uric acid :- 6.6 mg/dl

Calcium :- 9.6 mg/dl

Phosphorus :- 3.4 mg/dl

Sodium :- 132 mEq /L

Potassium :- 3.7 mEq/L

Chloride :- 98 mEq/L

RBS:- 79mg/dl

LFT:- 

Total bilirubin :- 2.12 mg/dl

Direct bilirubin:- 0.64 mg/dl

AST :- 17 IU/L

ALT :- 10 IU/L

Alkaline phosphatase:- 203 IU/L

Total proteins :-6.1 gm/dl

Albumin:- 2.2 gm/dl

A/G ratio:- 0.56

USG SCANNING OF WHOLE ABDOMEN:- 

Impression:- 

1) Bilateral GRADE 3 RENAL PARENCHYMAL CHANGES

2) MULTIPLE LARGE LEFT RENAL CALCULI .

3) Moderate to Gross ascitis 

COMPLETE URINE EXAMINATION:- 

Colour:- pale yellow

Appearance :- slightly hazy 

Specific gravity:- 1.010

PH:- Acidic (6.0) 

Proteins:- +++

Glucose :- Nil

Urobilinogen:- Negative

Bilirubin:- Negative

Ketones:- Negative

Nitrates :- Negative

Pus cells:- 5-6 /HPF

Rbc:- 5-7 /HPF

Epithelial cells:- 1-2/HPF

Casts:- Granular casts present

Crystals :- Nil

2D echo :-

Impression -

EF:- 48%

Dilated LA

Conc LVH 

Moderate MR/ Mild AR / Mild TR

No PAH/ No PE/ No CLOT

No RWMA

Sclerotic AV .

CT KUB : showing left kidney 7-8 cm Staghorn calculus causing mild hydronephrosis and thining of parenchyma

Ascitic fluid analysis showed - HIGH SAAG 

Examination videos links : 

https://youtu.be/FDq1rKdkIzQ 

https://youtu.be/SXvrJfDQzig 

https://youtu.be/p_W68yJ8Yu8 

Final diagnosis - 

Ascitis secondary to portal hypertension - ? Post hepatic -

Secondary to Congestive cardiac failure (HFPEF) 

Post renal AKI on CKD - Left staghorn calculus 

CKD - Stage 5 - Native kidney disease - ? Htn nephropathy 

Cardio- renal syndrome type 4