60 YEAR OLD 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 20 days.
-Decreased urine output since 15 days, not associated with frequency, urgency burning micturation.
-Grade 3 shortness of breath, no aggravating and relieving factors.
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, coherent,
non cooperative.
-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
-Spleen : not palpable
-liver : not palpable.
CNS examination:
Patient is 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 %.
3/12/23
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 1-2lts
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