58 yr old male with CKD ,recent MI, ? Spondylodiscitis

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box 



58 year old male, labourer by occupation, came to the OPD with the chief complaints of Shortness of breath since 30 days, worsened 1 day back, chest pain since 30 days ,facial puffiness since 30 days

History of Presenting illness - 
Patient was apparently asymptomatic 4 years ago

4 years ago - pt complained of giddiness, went to a local hospital and was diagnosed as Hypertensive, on regular medication since then T. Nicardia 10mg, T. Arkamine 0.1mg sos

2 years back Pt developed B/L pedal edema, progressed gradually to knees, diagnosed with renal failure and initiated dialysis weekly twice

Left upper limb swelling, gradually progressing to current size, since 4 months .
Also developed rt upper limb swelling since 4 days.
 Swelling in the left chest region, gradually progressing to current size, since 4 months
Back pain since 2 months, subsided on medication (T. Ultracet)

30 days back - developed
Shortness of breath ,

Grade II-III progressed to Grade IV since 30 days along with orthopnea .
Sob worsened 1day back, associated with dragging type of chest pain .came for dialysis last night.
Even after dialysis, chestpain did not subside
Ecg was done(18/01/22): ST elevations noted in V2,V3,V4

Repeat ecg done (on 19/01/22): 
ST elevations subsisded
C/o. generalized body pains
No c/o palpitations, giddiness, cold, cough, burning micturition


PAST HISTORY -

Known case of Hypertension since 4years on Tab nicardia 20mg OD
Not K/C/O TB, Epilepsy, Asthma, CAD.

Personal history:
Appetite- normal
Diet- mixed
Bowel movement- Regular
Alcoholic stopped 4 yrs ago
Non smoker


On examination:

Pt is C/c/c

No Pallor,Icterus,Cyanosis, clubbing,Lymphadenopathy

B/L pedal Edema(pitting type) present


Vitals
Pr:94bpm
Bp:120/80
Spo2:97% at RA
Temp - Afebrile



Systemic examination

CVS - S1,S2 +
RS - BAE + 
CNS - NAD
P/A- Soft, non tender


Investigations on 02/01/2022:

Repeat xray:
Serology - Negative
Ortho referral for back pain :

Investigations on 08/01/2022:
Serology: negative
Rft:
lft:
Ecg:

Xray on 21/01/2022:

Diagnostic pleural tap was done.

Post -pleural tap xray

Pleural fluid LDH 98
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 done


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-
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

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