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medicine case

NEPHROLOGY CASE

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


A 45 yr old male presented with complaints of 
BIATERAL PEDAL EDEMA SINCE 1 MONTH
ABDOMINAL DISTENTION SINCE 20 DAYS
SOB SINCE 15 DAYS 
DECREASED URINE OUTPUT SINCE 15 DAYS
SCROTAL SWELLING SINCE 1 DAY. 
HOPI
PT WAS APPARENTLY ASYMPTOMATIC 1 MONTH BACK , then he noticed BILATERAL PEDAL EDEMA OF PITTING TYPE , WHICH IS INSIDIOUS IN ONSET,  FOR WHICH HE VISITED TO LOCAL HOSPITAL AND GOT TO BE TOLD TO HAVE SOME KIDNEY ISSUE ( small kidneys) and RECEIVED SOME MEDICATION AND GOT RELIEVED FOR BRIEF TIME

AFTER 1 WEEK HE AGAIN DEVELOPED B/L PEDAL EDEMA OF PITTING TYPE WHICH IS GRADUALLY PROGRESSIVE FROM LEGS TO KNEE AND EXTENDED TO THIGH,, AGGRAVATED BY WALKIG AND STANDING, RELIEVED ON LYING DOWN,, 
THEN HE DEVELOPED ABDOMINAL DISTENTION
HE ALSO COMPLAINTS OF SOB SINCE 15 DAYS WHICH IS PROGRESSIVE FROM GRADE 1 TO GRADE 3,
ORTHOPNEA  PRESENT
PND PRESENT. 
URINE OUTPUT IS DECREASED SINCE 15DAYS.. 
NO H/O BURNING MICTURITION
HE DEVELOPED SCROTAL SWELLING SINE 1 DAY

Past history :


K/C/O DIABETIC SINCE 12 YRS.. RECEIVED MEDICATION FOR 2 YRS (INSULIN) 
AND STOPPED. 
NOT A K/C/O HTN, EPILEPSY, ASTHMA, TB
No drug history 
No previous surgeries 


FAMILY HISTORY :
NOT SIGNIFICANT 

PERSONAL HISTORY :
MIXED DIET
APPETITE NORMAL
BOWEL MOVEMENTS ARE REGULAR 
DECREASED URINCE OUTPUT SINCE 15 DAYS
SLEEP DECREASED 
HE IS CONSUMING ALCOHOL SINCE 20 YRS 2-3 TIMES A WEEK  -->180ML STOPPED 2 MONTHS BACK 
HE SMOKES BD  5 BEEDIS  per day since 30 yrs.. 
No known allergies 

General Examination :
Pt is conscious, coherent, cooperative moderately built and moderately nourished  

NO PALLOR 
NO CYANOSIS
NO ICTERUS
NO CLUBBING
NO GENERALISED LYMPHADENOPATHY
Bilateral pedal edema
Vitals:
PR 112 bpm
RR 25 bpm
BP 180/100 mmHg
SpO2 98%at room air


Systemic Examination 
CVS 
S1 S2 HEARD
 NO MURMURS
RESP :
Dyspnea: SOB
Wheeze: Absent
Position of trachea: Central
Breath sounds: Vesicular breath sounds heard
Bilateral rhonchi heard in all areas except infraaxillary region. 
BAE + NT
ABDOMEN :
Distended with everted umbilicus
SOFT, NON TENDER
NO ORGANOMEGALY
Fluid Thrill +

CNS:
INTACT

Provisional diagnosis :
AKI ON CKD SECONDARY TO DIABETIC NEPHROPATHY WITH COPD WITH ANEMIA OF CHRONIC DISEASE. 

Investigations:
CUE:

Serum electrolytes :
        Na -139
         K-4.7
         Cl -102 
Serum creatinine -3.8 #
Blood Urea -85 #
Prothrombim time -13 sec
APTT-27
INR -1.9#
Anti HCV antibodies-non reactive
HbsAg -negative
HIV - non reactive 
BLOOD grouping AB +ve 





TREATMENT:on 12/06/2021

 INJ. SODIUM BICARB.  200ml IV SLOWLY 

TAB. METALAZONE  5 mg PO/OD
INJ.LASIX 80mg IV STAT
TAB. NODOSIS 500 mg BD
TAB. SHELCAL CT OD
TAB. OROFERXT BD
INJ. ERYTHROPOIETIN S/C WEEKLY THREE TIMES 
INJ. IRON SUCROSE IN 100ml NS WEEKLY 2TIMES 
TAB. NICARDIA 20 mg BD
DAILY WEIGHT MONITORING 

Bp 180/100,weight 67kg

on 13/06/21
On examination. 
Pt conscious,  coherent ,cooperative 
Afebrile
PR 112 PER MIN
CVS  S1 S2 +
APEX BEAT 5TH ICS
PER ABDOMEN DISTENDED
FLUID THRILL +
RS: BAE+,END INSPIRATORY WHEEZE IN ALL AREAS B/L
Reticulocyte count: 0.5%



Rx:
INJ.LASIX 20mg per hour
TAB. NODOSIS 550 mg BD
TAB. SHELCAL CT OD
TAB. OROFERXT BD
INJ. ERYTHROPOIETIN  4000IU S/C WEEKLY once
TAB. NICARDIA 20 mg BD
DAILY WEIGHT MONITORING 
INJ. HAI S/C TID 
NEBULIZATION WITH BUDECORT 12TH HOURLY

On 14/06/2021:
Pt is C,/C,/C
Afebrile
PR 96per min
BP 150/90
P/A : DISTENDED, FLANKS FULL , gross ascites, pedal edema+,scrotal edema+

Rx:
One HEMODIALYSIS WITH ONE UNIT PRBC TRANSFUSION (fever with chills one episode during transfusion) 


INJ.LASIX 20mg per hour
TAB. NODOSIS 550 mg BD
TAB. SHELCAL CT OD
TAB. OROFERXT BD
INJ. ERYTHROPOIETIN  4000IU S/C WEEKLY once
TAB. NICARDIA 20 mg BD
DAILY WEIGHT MONITORING 
TAB.  Met xl 25mg.OD 2PM
NEBULIZATION WITH BUDECORT 12TH HOURLY

ON 15/06/2021:

PT IS C/C/C
AFEBRILE
BP120/60
CVS: S1 S2+
RS: NVBS +, END INSPIRATORY WHEEZE + IN ALL AREAS 
P/A: DISTENDED 

Rx:
INJ.LASIX 20mg per hour
TAB. NODOSIS 550 mg BD
TAB. SHELCAL CT OD
TAB. OROFERXT BD
INJ. ERYTHROPOIETIN  4000IU S/C WEEKLY once
Tab. Met xl 25mg po/od.
TAB. NICARDIA 20 mg BD
DAILY WEIGHT MONITORING 
NEBULIZATION WITH BUDECORT 12TH HOURLY
Tab metolazone 5mg po/od
INJ. MONOCEF 1 gram /iv/BD 

On 16/06/2021:
Pt is c/c/c 
Afebrile
BP:170/70mmhg
PR 93per min
Rs: NVBS +, END INSPIRATORY WHEEZE +VE IN ALL AREAS 
P/A : DISTENDED

On 17/06/2021:

Pt is c/c/c
One episode of fever spike 
Pedal Edema bilaterally increased. 
Bp 170/90 
PR 109 bpm
RS: End resp wheeze in nlinfra mid and supra scapular areas
GRBS -100 mg /dl 

Rx:
INJ.LASIX 20mg per hour
TAB. NODOSIS 550 mg BD
TAB. SHELCAL CT OD
TAB. OROFERXT BD
INJ. ERYTHROPOIETIN  4000IU S/C WEEKLY once
Tab. Met xl 25mg po/od.
TAB. NICARDIA 20 mg BD
DAILY WEIGHT MONITORING 
Tab metolazone 5mg po/od
INJ. MONOCEF 1 gram /iv/BD 
Plain INJ vancomycin 1gram through centralline. 




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