60M pedal edema and SOB

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60y old male patient farmer by occupation presented with cheif complaints of 

Bilateral lower limbs swelling since 5 days

Decrease urine output since 5 days

Fever during dialysis since 2 days.

Patient was apparently alright 1 year back following which he developed bilateral lower limb swelling associated with shortness of breath and decreased urine output and fever then he visited local physcian where he was diagnosed with chronic renal failure and referred to nephrologist near by and started medical management for CKD.

Since then patient is on conservative management for CKD for 6 months. 

6 months back he developed sudden onset of shortnessof breath associated with generalised body swelling then he went to a nephrologist near by and hemodialysis was initiated through RT IJV. 10 sessions of hemodialysis was done and Patient was referred to NIMS for further evaluation.

Patient was hemodynamically stable when he consulted to nephrologist in NIMS and they advised to pause the dialysis and managed with medication for 1 month and removed central line.

As patient felt better and re-energise patient didn't follow up at NIMS for 4 months and started doing his routine farming.

2 months back patient developed similar episodes of SOB at rest and pedal edema and undergone dialysis at Osmania through permacath placed in Rt IJV.

Since then patient is on maintainance Hemodialysis.

Since 2 days patient having chills and fever during dialysis and hypotension.

Personal history :

Appetite : decreased 

Diet : mixed 

Sleep : adequate 

Bladder : decreased urine output

Bowel movements: regular 

Addictions :absent 

 

General examination:

Pallor: absent

Icterus: absent 

Cyanosis : absent 

Clubbing : absent 

Lymphadenopathy : absent 

Edema : present B/L pitting type of pedal edema.

Vitals:

 Temperature: afebrile 

 Pulse: 119 bpm

 Blood pressure:140/80 mm of hg

 Respiratory rate : 28 bpm

SpO2 : 96 on RA

GRBS : 358 MG/DL

Systemic examination:

Cardiovascular system  

JVP -raised 

Visible pulsations: absent 

Apical impulse : left 5th intercostal space in midclavicular line.

Thrills -absent 

S1, S2 - heart sounds heard 

Pericardial rub - absent

Respiratory system:

Patient examined in sitting position

Inspection:-

oral cavity- Normal ,nose- normal ,pharynx-normal 

Chest shape : Barrel

Trachea is central in position.

Palpation:-

All inspiratory findings are confirmed

Trachea central in position

Apical impulse in left 5th ICS, 

Chest movements bilaterally symmetrical 

AUSCULTATION 

Decreased air entry on Rt side 

B/L crepts present ( Rt > Lt)

Abdomen examination:

INSPECTION

Shape : distended 

Umbilicus:normal 

Movements :normal

Visible pulsations :absent

Skin or surface of the abdomen : normal 

PERCUSSION- tympanic

AUSCULTATION :bowel sounds heard

USG : 

Labs : 

Fever chart

Diagnosis : 

CKD on MHD

Sepsis 2to ?CRBSI