159 RAVALI IRUGURALA

4-dec-2023

60 YEAR OLD MALE CKD ON MAINTENANCE HEMODIALYSIS WITH ANEMIA OF CHRONIC KIDNEY DISEASE WITH HYPERTENSION

This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input

A 60 year old male, who is a resident of Nalgonda ,farmer by occupation came with 

Chief complaints :
Pedal edema since 3 months.
Shortness of breath since 20 days. Decreased urine output since 15 days.

History of presenting illness:
The patient was apparently asymptomatic 3 months back when he noticed bilateral pedal edema initially extending to ankle Gradually progressed up to thighs which worsened during last 15 days.
Decreased urine output since 15 days, not associated with frequency, urgency burning micturation.
Grade 3 shortness of breath, no aggravating and relieving factors.

Before the presenting illness :
Patient had History of trauma by fall from tree 17 years back, where he used NSAIDS for 4/5 yrs ..
Then 12 years back he developed pedal edema where He got diagnosed that he had kidney problem and he was on medication and where edema was subsided and it was more recurrent on those 5 years.
Then he was diagnosed with CKD For which he got treated by dailysis initially and then he started using medications
 Patient was apparently well till 3 months     back
 3 months back patient developed   bilateral  pedal edema, facial puffiness  for  the first time and shortness of breath  so he visited local hospital and they  referred to our hospital for dailysis.
Since then patient was coming here regularly twice a weak for dialysis .

After his last dialysis session he went back home and he developed discomfort in chest and weakness of limbs . Patient also had few episodes of altered sensorium in between.
So he was brought to hospital again.

PAST HISTORY:
Known case of hypertension since 6 months
No history of diabetes mellitus, asthma, cardiovascular disease , epilepsy, tuberculosis
There is a history of blood transfusions.

PERSONAL HISTORY:
Mixed diet
Sleep adequate
Bowel-Regular
Bladder-Irregular
No known allergies
consumes alcohol occasionally 
Smokes tobacco

DAILY ROUTINE 
Before 3 years :
Wakes up at 5 am and goes to field and toddy trees 
Breakfast at 9 am -rice
Afternoon- lunch 12 pm
Evening drinks toddy 
And dinner by 9 pm and sleep
Now :
Wake up at 8 am 
Breakfast at 9 am
Skips lunch and dinner at 8 pm
He is not going to work,not as active as in the past

FAMILY HISTORY:
Father had Hypertension.
No history Tuberculosis, diabetes mellitus,etc.

GENERAL EXAMINATION:
Patient is conscious, non coherent,
non cooperative.
Gynaecomastia present.
pallor present.
clubbing is seen
No signs of icterus , generalized lymphadenopathy.
signs of bilateral pedal edema.( Pitting)

Pallor

Pedal edema

Clubbing
VITALS
Temp:100 F
PR: 98
RR: 29/ min
Bp:100/80 mm Hg. 
Spo2: 84%
GRBS:124 mg/dl

SYSTEMIC EXAMINATION:
Cardiovascular system: 
S1,S2 heard , no mumurs.

Respiratory system:
Position of trachea central.
Bilateral airway entry present.
Dyspnea present 
No wheeze.

Abdomen:
Scapoid
No tenderness
No palpable mass

CNS examination:
Patient has altered sensorium and he seems to be  irritable, non cooperative 
Slurred speech 
No delusions , hallucinations
MOTOR SYSTEM EXAMINATION
Bulk
                                  Rt           Lt
Upper limb 
           MAC       26 cm              26 cm
           MFAC     23 cm              23 cm
Lower limb
           MTC        33 cm               33 cm
           MLC        28 cm                28 cm
Tone
Upper limb 
Hypertonia in both right and left (3/5) Lower limb
Hypertonia in both right and left (3/5)
Power 
 Upper limbs - in right and left grade 3
 Lower limbs - in right and left grade 2 
Reflexes
Biceps   - Normal in both right and left
Triceps  - Normal in both right and left 
Supinator - Normal in both right and left     
Knee jerk relfex - Not elicited
Ankel reflex - Not elicited 
Plantor relfex - Not elicited
CEREBELLAR SIGNS :
Finger nose test -abnormal
Dysdiadochokinesia- 
Heel knee test -abnormal

PROVISIONAL DIAGNOSIS:
chronic kidney disease on maintenance hemodialysis with anemia secondary to chronic kidney disease with hypertension. uremic encephalopathy ? under evaluation

INVESTIGATIONS
On 28/11/2023
Hemogram
RFT
Serology
ABG
ECG
USG

On 29/11/2023
Hemogram
RFT
ABG
3/12/23 
Hemogram
RFT
4/12/23
Hemogram
serum creatinine
Blood urea
TREATMENT 
Patient was on salt restriction < 1.5 g / day 
Patient was on fluid restriction <1.5l per day 
Inj : PIPTAZ 2.25 gm iv /tid 
Inj LASIX 40 mg iv /bid 
Inj MEOMOL 14 mg iv sos if temp >101 
Tab : ECOSPRIN 50mg H/S 
Tab : OROFER once a day 
Tab DOLO 650 mg every 6 hourly 
Tab NODOSIS 500 mg PO /BD 
Tab SHELCALT 500 mg /BD

On 29/11/23
TAB. LINOD 10mg twice a day. 
Inj LASIX : 40 mg Iv twice a day 
Tab : Oral NODOSIS 500 mg twice a day 
Tab: Oral SHELCAL 500 mg twice a day
Inj.EPO 4000 IU ,SC once weekly
Tab : oral ECOSPRIN 75mg H/S
Inj NEOMAL : 14mg IV sos 
Tab : DOLO 650 mg QID
Inj PIPTAZ : 2.25 gm I.v thirice a day

On 30 /11/23 
Treatment 
Inj PIPTAZ : 2.25 gm I.v twice a day. 
Inj LASIX : 40 mg Iv twice a day 
Inj NEOMAL : 14mg IV sos 
 Tab : Oral NODOSIS 500 mg twice a day 
Tab: Oral SHELCAL 50 mg twice a day 
Tab : oral ECOSPRIN 50mg H/S
Tab OROFER once a day 
Tab : DOLO 650 mg QID
Intermittent CPAP 
Oxygen supplementation 1-2lts

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