66 year old male with complaints of shortness of breath since 1 week,generalized swelling since 1 week

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. 

Patient came to the casualty with chief complaints of shortness of breath since 1 week

Complaints of generalized swelling since 1 week

Hopi

Patient was apparently asymptomatic 1 year ago then he developed swelling in both lower limbs for which he went to asian institute of nephrology where he was diagnosed as having chronic kidney disease and patient was put on medication.patient again developed swelling of both limbs after 3 months and was taken to hospital and was advised hemodialysis in view of raised creatinine levels.

Total 5 hemodialysis were done till now 

Patient undergoes regular peritoneal dialysis

Last peritoneal dialysis was done one day before admission

Since 1 week patient has shortness of breath which was initially grade 3 and progressed to grade 4 associated with generalized edema 

K/c/o HTN since 10 years CINOD 10mg bd

K/c/o DM and on inj Hai bd

K/c/o IHD since 10 years

Cabg done in 2011

Not a k/c/o asthma, epilepsy,tb

3 hemodialysis was done on 23/7/22, 27/7/22 ,

1/8/22

Detailed history 

66 year old male, who is a father of 3 children ( 2 sons + 1 daughter).He used to sell the clothes by going to every village and take care of his family.

In 2011, patient had sudden onset chest pain, where he was taken to cardiologist and Angiogram was done , where the doctors told 3 vessels were blocked and Bypass surgery (CABG)was done.After his surgery , he stopped selling the clothes by going to Village and started a small shop were he used to sell the plastic material ( buckets, mugs etc ).

After 2 years ( in 2013), patient had Generalized weakness, where he was taken to hospital and found to be diabetic and hypertensive and started on medication.

Mean while patient had knee joint pains , where he used medication (pain killers ) from medical shop . According to daughter ,he almost used 10 years.

1 and 1/2 year back, patient developed pedal edema and shortness of breath on exertion, were he was taken to the hospital and found his renal parameters were deranged and started on conservative management.

Exactly 6 months back ( in July), the patient developed severe shortness of breath, and pedal edema worsened and patient was taken to nims , where central line was placed and started on hemodialysis ( 1 session done ).Then they came to our hospital and 3 sessions of hemodialysis done.Mean while , patient was in altered sensorium also, he pulled his central line, but not completely removed , after 3 sessions of hemodialysis,his sensorium improved

Then he was taken to the hospital in Hyderabad, where he was suggested to have peritoneal dialysis and daily one session done.

The same peritoneal dialysis was done for 5 month.

On Feb 8th , patient was started on 3 sessions of peritoneal dialysis per day, but his shortness of breath was not controlled and so he was brought here for further evaluation.

General physical examination

Vitals

Temp 98.6

Bp 150/80

PR 96

Systemic examination

CVS s1s2 heard 

No murmurs

Rs bilateral air entry present

Per abdomen software non tender 

CNS intact

No focal neurological deficits

Diagnosis

CKD on MHD dyselectrolytemia secondary to ?renal losses

S/P cabg done in 2011

Treatment given

Iv fluids urine output+30ml/hr

Inj lasix 40mg po/bd

Tab nodosis 500mg po/od

Tab shelcal 500mg po/od

Cap bio D3 po weekly twice

Tab cinod 10mg po/bd

Inj hai s/c tid 

On 27/2/23

Patient is on mechanical ventilator

Bp is 60 systolic

15ml/HR NORAD 

5ml/hr dobutamine 

Inj NORAD 2amp 10ml/hr in 46ml NS increase or decrease according to MAP

Inj dobutamine 2amp 5ml/hr in 45 ml NS increase or decrease according to MAP

RT feeds 

Water 2nd hourly 

Milk 6th hourly

Inj fentanyl 2amp 5ml/hr in 46 ml/ns 

Inj atracurium 2amp 5ml/hr in 46 ml NS 

Investigations

ECG

USG abdomen and pelvis

hemogram 

Hb 9.7

TC 10400

N 80

L 07

PCV 29

MCV 86.5

RBC 3.40

PLT 3.76

Tb 0.93

DB 0.20

Ast 35

Alt 21

Alp 278

Tp 4.6

Albumin 2.4

A/G 1.07

Urea 87

Creatinine 5.2

Uric acid 8.0

Calcium 8.2

Phosphorus 4.6

Sodium 127

Potassium 3.2

Chloride 89

Bgt b positive

Cue albumin present

Pus cells 3-4

Epithelial cells 2-3

Hba1c 6.8

Serum osmolality 285

Rbs 174

ABG

pH 7.32

Pco2 46.5

Po2 52.1

Hco3 26.2

Spot urine protein 55

Spot urine creatinine 96.1

Ratio 0.57

On 27/2/23

Hb 9.6

TC 9800

N 82

L 07

PCV 29.8

MCV 89.0

RBC 3.35

PLT 3.63

Urea 54

Creatinine 3.9

Uric acid 5.6

Calcium 7.9

Phosphorus 45

Na 130

K 3.5

Cl 94

ABG 

pH 7.16

Pco2 65.9

PO2 56.8

Hco3 22.8

On 2/3/23