SHORT CASE-2

A 55-year-old male, resident of Nalgonda, who is a farmer by occupation came to the hospital with chief complaints of breathlessness since 6 months

• HOPI : 

Patient was apparently asymptomatic for 20 years then had muscle cramps, increased frequency of urination, and giddiness for which he went to hospital and was diagnosed with DM type II and is on medication (T.Glymiperide + Metformin) since then.

1 year back he had generalized weakness, polydipsia, polyurea, and dizziness, visited the hospital and was found to have uncontrolled DM 2 and is on insulin ( since then.

Until 6 months ago he worked as a farmer, waking up at 5 am. he takes his breakfast at 7 am. Then he goes to work, has lunch at 1 pm. returns to home at 6-7 pm & has dinner at 8 pm, and goes to bed at 9 pm. 

But 6 months back his whole life was changed when he was taken to the hospital after experiencing palpitations, dizziness, blurring of vision, and involuntary movements involving his upper limbs & body, where he was diagnosed with hypertension & Renal failure.

H/o SOB since 6 months NYHA 1-2 and from last 1-month shortness of breath increased NYHA 3-4, gradually progressive, associated with orthopnea & PND for which he came to our hospital.

H/o Low backache since 1 month 

H/o itching all over the body with darkening of skin since 1 month

H/o decreased Urine output since 1 month

No thin stream, poor flow, increased frequency, hesitancy, or Burning micturition present.

No h/o Fever, Chest pain, Palpitations, Syncope

No h/o Cough

No other complaints

 

•Past History : 

K/c/o DM-type II since 20 years 

K/c/o hypertension since 6 months

No history of asthma, TB, epilepsy, thyroid abnormalities

•PERSONAL HISTORY: 

Diet: Mixed

Appetite: Normal

Sleep: Disturbed 

Bowel: Regular

Bladder: Decreased urination.

Habits: Do not consume any form of alcohol or tobacco.

●FAMILY HISTORY: 

Not significant

●DRUG HISTORY:

HAI & NPH 3 units (three times a day) Insulin for the past 1 year, 

TELMA for hypertension since the past 6 months

●GENERAL EXAMINATION:

The patient was examined in a well-lit room after obtaining consent.

The patient was conscious, coherent, and cooperative. He was moderately built and moderately nourished. 

Pallor: Absent

Icterus: Absent

Cyanosis: Absent

Clubbing: Absent

Generalized Lymphadenopathy: Absent

Pedal Edema: Absent 

 

Hyper pigmented dry scaly patches over the skin 

Itchy hyperpigmented lesions over right shoulder

Vitals : 

Temperature - Afebrile

BP - 130/80 mm Hg

Pulse - 78 BPM

RR - 24 CPM

Rbs - 124 mg/dl @ 7pm

●SYSTEMIC EXAMINATION:

Cardiovascular system:

•Inspection:

Shape of the chest appears to be elliptical & bilaterally symmetrical

Apex beat is not visible

No scars, sinuses, dilated veins 

No precordial bulge is seen.

•Palpation:

All inspectory findings are confirmed

Trachea is central 

Apex beat felt at 6th intercostal space 1cm lateral to midclavicular line.

•Auscultation:

In Aortic, Pulmonary, Tricuspid & Mitral areas

S1 and S2 heard.

No murmurs heard

Respiratory system:

•Inspection

Shape of chest appears to be elliptical and bilaterally symmetrical.

Trachea appears to be central

No scars, sinuses, or engorged veins.

Symmetrical expansion of the chest

•Palpation:

All inspectory findings are confirmed

Trachea appears to be central

Tactile vocal fremitus normal in all areas

•Percussion:

Resonant note is heard in all areas

•Auscultation :

Normal vesicular breath sounds are heard.

No adventitious breath sounds.

ABDOMEN:

obese abdomen

Moves symmetrically with respiration

Umbilicus is central and inverted

No scars or sinuses

No local rise in temperature

No organomegaly

CNS:

Higher mental functions intact.

Motor examination:

Power: B/l Upper limbs: 4 + bilaterally

              B/l Lower limbs: 4 + bilaterally.

Tone: Normal

Reflexes:        R           L

Biceps:           2+          2+

Triceps:          2+          2+

Knee:              2+          2+

Ankle:             2+          2+

Sensory examination: normal.

Cerebellar examination: normal.

Cranial nerve examination: normal.

Provisional diagnosis:

Acute on chronic LVF

Chronic renal failure since 6 months with?Uremic pruritis

K/c/o DM-type II for 20 years

K/c/o Hypertension for 6 months

●Investigations : 

X-Ray chest 

Interpretation : 

Cardiomegaly

Blood Investigations : 

HEMOGRAM:

Hb - 8.2 gm/dl

PCV - 23.9 vol%

MCV 79.1 FL

RBC count - 3millions/ cumm

Total leucocyte count-6900cells/cumm

Platelets-2.2lakhs/cumm

RFT:

Urea               - 119 mg/dl

Creatinine     - 7.9 mg/dl

Uric acid        - 7.7 mg/dl

Phosphorous- 4.7 mg/dl

Sodium          - 141 mEq/L

Potassium     - 4.7 mEq/L 

Chloride        - 103 mEq/L

LFT:

Total bilirubin -0.52mg/dl

Direct bilirubin- 0.18mg/dl

Alkaline phosphatase - 200IU/L

Total Proteins               - 5.8 gm/dl

Albumin                        - 3.14 gm/dl

RBS - 467mg/dl

CUE:

Albumin-   3+

Sugars-   4+

Pus cells :2-4cells/HPF

Epithelial cells: 3-4cells/HPF

ECG

Sinus Tachycardia

Heart rate: 100

2D ECHO:

USG Abdomen :

Bilateral Grade 2 RPD changes

Left Renal cortical cyst 

Left Renal calculus

• Final Diagnosis: 

Heart Failure with mid range ejection fraction EF: 48%

Chronic kidney disease secondary to Diabetic Nephropathy on Maintenance Hemodialysis

? CKD associated pruritus (Uremic pruritus)

K/c/o DM-type II for 20 years

K/c/o hypertension for 6 months

• Treatment :

Fluid restriction <2L /day

Salt restriction <2g /day

INJ HAI & NPH 3Units

Tab Lasix 40 mg BD

Tab Nicardia 20 mg PO/TID

Tab Arkmain 0.1mg PO/TID

Tab Orofer -XT PO/OD

Hemodialysis