35 year old man with C/O Chest pain, Cough and Shortness of breath.

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CASE PRESENTATION:

35 year old man from Ammanabolu, shepherd by occupation came with the chief complaints of Chest pain, Shortness of breath and cough.He is a known case of chronic kidney disease on maintenance hemodialysis since 6 months.

Patient was apparently asymptomatic 4 years back when he first experienced giddiness and headaches. He went to a local doctor and was then diagnosed with Hypertension. Since then he was on regular medication.He also recalled having mild shortness of breath on and off.

6 months back he developed Pedal edema, facial puffiness and decreased urine output and went to a local hospital where he was said that his kidneys failed and he require dialysis.

Since then he was on dialysis twice a week. 

On the 18th of December 2020 he finished he dialysis and went home when he started experiencing chest pain which is of dragging type, non radiating, not associated with any palpitations or sweating.He also complained of cough with expectoration which was mucoid in nature.

His shortness of breath worsened and was present even on lying down. He then came back to hospital on 20 December and got admitted. He says he feels better while lying down on left side.

The patient is married, doesn’t have any children.

He is a non smoker and was an occasional 

alcoholic stopped 6 months back.

O/E:

Pallor + 

Pedal edema + , pitting type.

No Clubbing, cyanosis, lymphadenopathy.

The patient is conscious and coherent.

He is afebrile to touch.

PR : 102 bpm

BP: 170/100 mm of Hg

RR: 30 cpm

CVS : S1, S2 heard

RS: Chest expansion - unequal

Decreased breath sounds in the Left Inframammary, infraaxillary , infrascapular areas.

P/A : soft, tenderness in the epigastric region.

CNS: intact

Provisional Diagnosis: K/C/O CKD on MHD with left sided pleural effusion.

Further Investigations:

2D Echo findings:

No RWMA.

Concentric LVH.

Moderate TR with Mild PAH

Moderate MR and AR

Sclerotic AV

No AS or MS

Good LV systolic function

EF = 58%

No diastolic dysfunction.

Mild to moderate PE

Mild dialted LA and RA

IVC dilated.

USG chest was done:

Final diagnosis: K/C/O CKD on MHD with left sided pleural effusion with mild pericardial effusion.

Treatment:

Day 1:

Inj. LASIX 40 mg IV/ BD

Inj. CEFTRIAXONE 1 g IV / BD

Tab. NICARDIA 20 mg PO / BD

Tab. NODOSIS 500 mg PO / BD

Inj. TRAMADOL 1 Amp in 100 ml NS IV / SOS

Inj. PAN 40 mg IV / BD

Tab. OROFER XT PO / BD

Tab. SHELCAL CT PO / OD

Dialysis done. Ultrafiltrate - 3.5 lit

Day 2:

Inj. LASIX 40 mg IV/ BD

Inj. CEFTRIAXONE 1 g IV / BD

Tab. NICARDIA 20 mg PO / BD

Tab. NODOSIS 500 mg PO / BD

Inj. TRAMADOL 1 Amp in 100 ml NS IV / SOS

Inj. PAN 40 mg IV / BD

Tab. OROFER XT PO / BD

Tab. SHELCAL CT PO / OD

Day 3:

Inj. LASIX 40 mg IV/ BD

Inj. CEFTRIAXONE 1 g IV / BD

Tab. NICARDIA 20 mg PO / BD

Tab. NODOSIS 500 mg PO / BD

Inj. TRAMADOL 1 Amp in 100 ml NS IV / SOS

Inj. PAN 40 mg IV / BD

Tab. OROFER XT PO / BD

Tab. SHELCAL CT PO / OD

Dialysis done. Ultrafiltrate - 3.5 lits

Day 4 :

Inj. LASIX 40 mg IV/ BD

Inj. CEFTRIAXONE 1 g IV / BD

Tab. NICARDIA 20 mg PO / BD

Tab. NODOSIS 500 mg PO / BD

Inj. TRAMADOL 1 Amp in 100 ml NS IV / SOS

Inj. PAN 40 mg IV / BD

Tab. OROFER XT PO / BD

Tab. SHELCAL CT PO / OD

Pleural tap was done.