A 60 year male CKD on maintenance hemodialysis
A 60 year male CKD on maintenance hemodialysis with anemia of chronic disease with hypertension.
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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.
Series of events :-
History of trauma by fall from tree 17 years back, where he used NSAIDS for 4/5 yrs .. and then 12 years back he developed pedal edema where he got diagnosed that he had kidney problems and he was on medication for where edema was subsided and it was more recurrent on those 5 years.
And after that 2 years later he got scrotal swelling ( which may be due to generalised anasarca)which got infected followed by trauma which was associated with fever and pain then he was diagnosed with ckd For which he got treated by dailysis initially and then he started using medications and 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 which was associated with fever and chills .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:
-Gynaecomastia present
- Patient is in altered sensorium,irritable
non cooperative.
-pallor present.
- clubbing is seen
- no signs of icterus , generalized lymphadenopathy.
-signs of bilateral pedal edema.( Pitting)
Pallor;
Pedal edema:
Clubbing:
VitalsTemp:100 F
PR: 98bpm
Rr: 29/ min
Bp:100/80 mm Hg.
Spo2: 84%
GRBS:124 mg/dl
Systemic examination:
Cardiovascular system:
-S1,S2 heard , no mumurs.
- impulse felt at epigastric region ( due to right ventricular hypertrophy which may be due to cor pulmonale)
Respiratory system:
-Position of trachea central.
- shape of chest -- barrel shaped
- Bilateral airway entry present.
-Dyspnea present
- no wheeze.
Abdomen:
-Scapoid
-No tenderness
-No palpable mass
-Spleen : not palpable
-liver : not palpable.
CNS examination:
Patient is in altered sensorium and he seems 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 left and right (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 of chronic disease with hypertension. uremic encephalopathy ? under evaluation
Investigations:
28/11/23:
Hemogram
- Hemoglobin:5.4gm/dl.
-total count: 26,800
-Neutrophils- 89
-lymphocyte:5
-eosinophil:06
- monocyte :0
-Basophils:0
-PCV : 16.1
-MCV : 84.1
-MCH : 28.1
-MCHC : 33.4
-RDW -CV :22.9
-RDW-SD : 66.3
- platelet count : 1.32
Impression: Normocytic Normochromic with neutrophilic leukocytosis and thrombocytopenia.
Renal funtion test :
Urea 131 mg/dl
Creatinine 4.6 mg /dl
Uric acid 9.9 mg/dl
Calcium 10.1 mg/dl
Phosphorus 5.1 mg /dl
Sodium 137 meq /l
Potassium 4.1 meq / l
Chloride 102 meq/l.
Serology;
-HIV 1/2 Rapid : Non reactive
-Anti HCV antibodies Rapid : Non reactive
-HBsAg Rapid : negative
ABG;
PH 7.46
Pco2 29.4mmhg
Po2 165 mmHG
Hco3 20.7 mol /l
Tco2 44.9 vol
O2 sat 98.8%
O2 count 8.9vol %
ECG :
Ultra sound:
29/11/23
Renal funtion test
Urea 146 mg/dl
Creatinine 7.7 mg /dl
Uric acid 10.8 mg/dl
Calcium 9.9 mg/dl
Phosphorus 5.6 mg /dl
Sodium 129 meq /l
Potassium 4.7 meq / l
Chloride 89 meq/l.
Hemogram
- Hemoglobin:5.4gm/dl.
-total count: 22,300
-Neutrophils- 91
-lymphocyte:4
-eosinophil:0
- monocyte :5
-Basophils:0
-PCV : 16.2
-MCV : 84.4
-MCH : 28.3
-MCHC : 33.5
-RDW -CV :22.1
-RDW-SD : 66.9
- platelet count : 1.52
Impression: Normocytic Normochromic with neutrophilic leukocytosis.
ABG analysis:
PH 7.74
Pco2 25.9 mmhg
Po2 46.1 mmHG
Hco3 19 mol /l
Tco2 43.3 vol
O2 sat 92.4 %
O2 count 2.4 vol %.
2D Echo:
Fever charting:
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.
On 28 /11/23
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 1-2 lts