60 yr old male

 

A 60 year male CKD on maintenance hemodialysis with anemia of chronic disease with hypertension.

December 03, 2023

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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.

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 %.

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