Hypertension & Renal Dysfunction Clinical Case

CLINICAL CASE 01

 

A Patient With Severe Hypertension and Renal Dysfunction

Clinical Case | Investigations | Diagnosis | Management

 

1.PRESENTING COMPLAINTS WITH BRIEF HISTORY:

patient is presented with complaints of light-headedness, dizziness, palpitation since today afternoon. Past History: permacath insertion done on (date) CKD stage 5D (twice weekly), last HD done on(RELEVANTDATE), ILD, OSA, hypertension, diabetes mellitus type II, anemia.

2.CLINICAL EXAMINATION:

Conscious, oriented, moving all 4 limbs, speech normal

2D Echo was done which showed no RWMA of LV, LVEF-60%. Mild LVH.

High normal LA. Mild (2+) MR. Mild TR (PASP=31mmHg). Sclerotic aortic valve, Mild AR. No AS. Diastolic relaxation abnormality present. No IC/clot/ mass/vegetation/PE.

USG Whole Abdomen was done which showed bilateral medical renal disease. Grade-l prostatomegaly. Left sided pleural effusion.

Ophthalmology opinion was taken and advised for Fundus Examination which showed grade Ill Hypertensive retinopathy both eyes.

Hemodialysis was done on (anydate)

Patient needs hospitalization and further management. However, on account of persistent request for discharge from patient & attendant side. Patient is being discharged on request with follow up advice.

3.Diagnosis:

a.ACCELERATED HYPERTENSION

b.ILD

.LEFT-SIDED PLEURAL EFFUSION

d.OSA

e.CKD STAGE 5D

* BILATERAL SMALL KIDNEYS

* PERMACATH IN SITU SINCE 21.05.2026

* LAST HD DONE ON 18.07.2026

f.HYPERTENSION

* GRADE III HYPERTENSIVE RETINOPATHY

g.TYPE II DIABETES MELLITUS

h.EF - 60%

i.SEVERE ANEMIA

 

4.TREATMENT ADVISED:

MHD(maintenance hemodialysis) @3/ WEEK

TAB CEFOPRIM 250 MG 1 TAB TWICE DAILY FOR 5 DAYS

TAB PAN 40 MG 1 TAB ONCE DAILY BEFORE MEALS

TAB ARKAMINE 0.1 MG 1 TAB THRICE DAILY

TAB NICARDIA- XL 30 MG 1 TAB THRICE DAILY TAB. MINIPRESS XL 5MG 1TAB TWICE DAILY

TAB. LONITAB 5MG 1TAB THRICE DAILY

TAB ISOLAZINE 20/37.5 MG 1 TAB TWICE DAILY

TAB DYTOR 40 MG 1 TAB TWICE DAILY

CAP URIMAX 0.4 MG 1 CAP ONCE DAILY AT BEDTIME TAB ALTYSEV DT 400MG THRICE DAILY WITH MEALS

SYP. LACTIHEP 30ML THRICE DAILY INJ. CRESP 40MCG S/C ONCE WEEKLY NEPHRO-HP POWDER 2SCOOPS THRICE DAILY EYE DROPHYLASOFT 1DROP TWICE DAILY

 

5.ADVICE ON DISCHARGE:

Low salt intake 3gram/day

Protein 60GM daily Calorie intake: 2100kcal/day

Fluid restriction <800ml/day

Avoid pain killer (NSAIDS) and nephrotoxic drugs 

Medical Disclaimer: The information provided in this article is strictly for educational, study, and exam-preparation purposes. It does not constitute professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider for clinical decisions.