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60 yr old male

 

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.

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

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