A 65 year old male with anasarca

65 year old male with anasarca 

 A 65 Yr old male resident of narketpally, vro by occupation came to hospital on 8 November with

C/O :

• B/l pedal edema since 2 weeks
• Shortness of breath since 2 weeks

Hopi :

• Patient was apparently asymptomatic 3 yrs back then he developed hemiparesis on right side and he was put on antiplatelet
• Then he was diagnosed with diabetes and hypertension 
• He also had complains of b/l pedal edema after which they diagnosed him with CKD

• Now,  2 weeks back he started developing edema which is insidious onset, gradually progressive, associated with pain. 
• It started on legs, then progressed to hands abdomen and face in that order. 
• Edema aggravated on walking and not relieved on medication. 
• It is associated with shortness of breath which is grade 4 on NYHA classification 
• Associated with decreased urine output 
• No associated fever, chest pain, cold 

Past history : 

• H/o diabetes mellitus since 3 years 
• H/o HTN since 1 1 /2  years 
• H/o kidney disease since 3 years 
• No H / o TB, Asthma, epilepsy. 

Drug history : 

• Human actrapid inj for DM 

Surgical history :

• No H/o surgeries 

Personal history :

• Diet            : mixed 
• Apetite      : reduced 
• Bowel.       : regular
• Bladder.    : reduced 
• Addictions : used to consume alcohol 3years back 

General examination : 

• Pallor - present 
• Icterus - absent 
• Cyanosis - absent 
• Clubbing - absent 
• Lymphadenopathy - absent 
• Pedal edema - present 

Systemic examination : 

1. CVS examination : 

• Inspection : JVP is raised, normal shape and movements of the chest. 
• Palpation : apex beat - 5 th intercostal space, no abnormal pulsations felt.
•  Auscultation : s1 and s2 heard, no murmurs

    2. Abdominal examination : 

• Inspection : distended abdomen, umbilicus is crescent shape, movement - equal in all quadrants. 
• Palpation : liver, spleen not palpable, fluid thrill present 
• Percussion : no shifting dullness 
• Auscultation : Bowel sounds present, no bruit 

     3. Respiratory system : 

• Normal vesicular breath sounds 

Investigations : 

Diagnosis :  Acute left Heart failure and Chronic kidney disease on MHD 

Treatment:

Fluid restriction 

Inj Lasix 40 mg / IV / Stat followed by inj Lasix 20 mg @ 2.5 ml / hr

Inj Pantop 40 mg IV/OD

Inj Zofer 4 mg IV/SOS 

Nebulisation with duolin and budecort 8th hourly 

Tab Ecosprin AV ( 75/ 20 ) PO/ H/S

Tab Amlong 10 mg PO/ H/S

Inj HAI S/C pre meal acc to sliding scale 

Weight monitoring daily 

Foleys catherisation done 

Pleural tap done I/v/o Rt sided gross pleural effusion

Pleural fluid analysis:

Sugar- 198

Protein- 0.7

LDH- 154

Chest x ray : 

After pleural tap :