38 year old male on dialysis

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I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my cmpetancy i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

March 10th, 2022

Preity Yarlagadda

Roll no: 145

Medicine case :

A 38yr old male , who works in a book stall 

HAS BEEN ON DIALYSIS SINCE 6YRS.

Yesterday night he came with

 c/o shorteness of breath ,pedal edema, abdominal distension and got admitted. 

He cannot walk on his own, needs support.

Yesterday's vitals:

Bp:140/90mmhg

RR: 28cpm

Spo2: 98% RA.

Today he has a dialysis session.

His last dialysis was about a month ago

He comes under day care basis usually.

He has AV fistula to his left arm.

H/O HTN since 2yrs on tab. NICARDIA 20mg

Today mrng at 9:00am his 

BP : 190/110mmhg 

RR: 26cpm

After nebulization, sob decreased to some extent. RR: 20cpm.

After giving NICARDIA 80mg i.v , after 1hr his BP came down to 150/90mmhg.

Past history :

H/O alcohol since 20yrs, every alternate day around whiskey 200ml/day. Now since 2-3yrs he stopped consuming alcohol.

He is a smoker since 20yrs, smokes around 20-30 cigarettes per day, before 6yrs.

NOW HE SMOKES AROUND 10-12 CINGARETES PER DAY

No H/O DM, EPILEPSY, THYROID, TB ASTHMA.

Personal history:

Occupation: book seller

Married. Has a healthy daughter with age of 10yrs.

He was apparently asymptomatic 6yrs back.

His daily routine was, he used to wake up around 7, undergo his daily natural activites, goes to book stall around 10, comes to house for lunch in the afternoon, goes back to work again. Though he was regular to his work,even before 6yrs. He used to stay at home for almost 2-3 days a week.

In the eve with his friends around his house, consumes alcohol around 250ml a day whiskey.

Smokes around 20-30cigarretes per day.

Now he is not working, stays at home.

Before 6yrs, he went to nearby hospital with complaints of loss of appetite since 1mon , pain abdomen, shorteness of breath , pedal edema.

Got diagnosed as renal failure and has been sent to our hospital for dialysis.

Since then he was been under dialysis.

In between he used to have episodes of shorteness of breath and pedal edema, got relieved after dialysis and by taking regular medication.

Before 2yrs he was been hospitalized with complaints of grade 4 shorteness of breath, pedal edema and pain abdomen.

He has been diagnosed DENOVO HTN.

On regular medication.

In his xray , plueral effusion was noted in left side.

3 times pleural tap was done.

1time PRBC Transfusion was done

and got discharged.

Continued dialysis sessions on day care basis.

Before 2months ,he developed abdominal distension, gradual in onset , progressive, not relieving.

General examination :

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS:

CKD ON MHD .

PLAN OF CARE:

Fluid restriction<1lt/day

Salt restriction<2.4gm/day

Inj. Lasix 40mg i.v /TID

Tab. NICARDIA 20MG PO/TID.

Tab. SHELCAL po/od

Tab. Orofer xt Po/od

Inj.erythropoietin 4000IU S/C weekly once

Inj. Iron sucrose 1ampoule in 100ml NS during dialysis.