A 65yr old M with Hypoglycemia,Hypotension

 A 58 year old male, labourer by occupation, came to the OPD with the chief complaints of Shortness of breath since 30 days,which was worsened 1 day back(19/02/22), chest pain since 30 days ,facial puffiness since 30 days

History of Presenting illness -  

Patient was apparently asymptomatic 3 years ago then developed giddiness,  for which he went to a local hospital and was diagnosed as Hypertensive, for which he is taking T. Nicardia 10mg, T. Arkamine 0.1mg sos.

Then 2 years back he  developed B/L pedal edema,  which progressed gradually to knees and  diagnosed with renal failure, started dialysis weekly twice.

Since 4 months he developed left upper limb swelling and swelling at chest region,both of  which got  progressed to current size. 

Back pain since 2 months, which got subsided on medication (T. Ultracet). 

30 days back - he developed shortness of breath ,Grade II-III  which progressed to Grade IV since 30 days associated with orthopnea .

Whereas from 4 days he developed right upper limb swelling. 

But sob worsened 1day back(19/02/22), along with dragging type of chest pain and came for dialysis last night. 

Even after dialysis, chestpain did not subside. 

Ecg was done(18/01/22): ST elevations noted on V2,V3,V4

Repeat ecg done (on 19/01/22):  

ST elevations subsisded.

Patient complains of generalized body pains 

No c/o palpitations, giddiness, cold, cough, burning micturition

PAST HISTORY -

Known case of Hypertension since 4years for which he is taking  Tab nicardia 20mg OD. 

Not K/C/O TB, Epilepsy, Asthma, CAD.

Personal history: 

Appetite- decreased 

Diet- mixed 

Bowel and bladder movement- Irregular 

Addictions: he used to consume toddy but stopped 3 years ago.He is a non-smoker. 

On examination:

Pt is conscious,coherent,co-operative,well oriented to time,place,person.

No signs of Pallor,Icterus,Cyanosis, clubbing,Lymphadenopathy 

Bilateral pitting type of pedal oedema is present.

Vitals 

Temp - Afebrile

Pr:94bpm 

Bp:120/80 

Spo2:97% at RA 

Systemic examination

CVS - S1,S2 + 

RS - BAE +  

CNS - NAD 

P/A- Soft, non tender

Investigations on 02/01/2022:

2D Echo:

X RAY:

Serology: negative

Ortho referral for back pain :

Investigations on 08/01/2022:

Serology: negative

Rft:

LFT: 

ECG

X RAY ON 21/2/22:

Diagnostic pleural tap:

X RAY After pleural tap:

Pleural fluid LDH

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: 

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 

Salt restriction

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