48 YEAR OLD PATIENT -CKD

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46 yr old male patient who is tailor by occupation came to hospital for dialysis 

Cheif complaints: post dialysis fever with chills 

HOPI:

Pt was apparently assymptomatic 20 yrs back then he developed lower  back pain for which he visited to hospital and diagnosed with renal calculi for which he used medication for 3 years  ,still his lower back pain didn't subsided so he visited to some rmp and used NSAIDS for 10-15 years ,later on 3 years back one day he developed bilateral pedal edema with sob he visited to hospital and diagnosed with CKD and HTN and using regular medication with regular followup due  to covid 19 lockdown he didn't had regular checkups using medication  ,3 months back when he visited to hospital then he was told to have high creatinine (around 11 ,acc to patient) and need for dialysis intervention ,then he was started on dialysis .

10 yrs back he was diagnosed with diabets mellitus

Family history: His father suffered with kidney problem

Personal history: Diet: normal

Appetite: decreased

Sleep :adequate

Bowel and bladder moments: not regular

Addictions:10 yrs before there is a history of intake of alcohol

DAILY ROUTINE:3 yrs back he used to wakeup at 6 mrng and do his regular activities 

like getting up from the bed, walking on his own,using wahsroom and having food by his own and then he used to do tailoring rest of the day (he used to have irregualr sleep and food intake pattern when there is heavy work load)

from 3 yrs his daily routine is disturbed he is doing tailoring less frequently

 before dialysis he cannot do his own work and someone have to feed him.

Examination:

General examination:

Patient is conscious,coherent and cooperative,well oriented to time,place and person

Vitals at the time of admission: 

Temp-98.5

PR-92bpm

RR-26cpm

BP-130/70 mmHg

Spo2-93

There is pallor

No icterus

No cyanosis,

No clubbing 

No lymphadenopathy

There is bilateral pedal edema

Systemic examination:

CVS- S1S2 heard 

RS- dyspnea present

P/A- soft,non tender

CNS- NAD 

Diagnosis: CKD 

Known case of DM  and HTN

Complains currently- (4/1/22)

Chills and fever post hemodialysis since the past 1 month

1 session of hemodialysis done on -3/1/22

P/A examination on 5/1/22 -soft,tender

Examination on 6/1/22- he is afebrile

done 1 session of dialysis today

he have chills

pulse: 84bpm

respiratory rate: 20 cycles/min

P/A: soft ,tender

Investigations:

RFT

USG

abnormal values:total biluribin-1.06

direct biluribin-0.22

alkaline phosphatase-301

total proteins-4.9

albumin-2.5

urea-83

creatinine-6.4

clinical pictures:

RX

1 fluid restriction <2 litre/day

salt restriction <2g/day

2 tab lasix 40 mg po/bd

3 tab nicardia 10 mg po/bd

4 tab nodosis 500mg po/bd

5 tab shelcal ct po/od

6 tab orofer-xt po/od

7 inj erythropoetin 4000 IU 

s/c weekly once

RE ADMISSION:(28/2/22)

CHIEF COMPLAINTS :shortness of breath,pedal edema,swelling of hand

HOPI: on 27/2/22 he completed his dialysis and went home and then on 27/2/22 night 2pm he got severe sob so they got admitted in the hospital on 28/2/22 6am .

he is having sob even on rest since 1 month

also having pedal edema extending up to knee which is pitting type since 1 month

he is having swelling of upperlimb which is insidious in onset and gradually progressive since 2 months

intially there is swelling of only left upperlimb but later there is swelling of both the upperlimbs

PAST HISTORY:

there are similar complaints of sob and pedal edema and in the past

PERSONAL HISTORY :

Appetite:normal

Mixed diet

Sleep:disturbed 

Bowel movements regular

Bladder movements decreased

GENERAL EXAMINATION:

patient is conscious,coherent and cooperative well oriented to time place and person

vitals:

Temp-98.6

PR-82bpm

RR-22cpm

BP-140/90 mmHg

Spo2-98 at 12 litres of oxygen

There is pallor

No icterus

No cyanosis,

No clubbing 

No lymphadenopathy

There is bilateral pedal edema

GYNAECOMASTIA PRESENT

SWELLING OF HANDS PRESENT

SYSTEMIC EXAMINATION:

CVS:

S1 AND S2 HEARD

NO THRILLS

NO MURMURS

RESPIRATORY SYSTEM:DYSPNEA PRESENT

PER ABDOMEN:SOFT NONTENDER

CNS:NAD

INVESTIGATIONS:

ABG

PH:7.32*(7.35-7.45)

Pco2:43.5

Po2:191*(80-100mmhg)

Hco3:22.2

TREATMENT:Fluid restriction (<1.5l/day)

Salt restriction (<2g/day)

Tab.LASIX 40mg BD

Tab.METOR 5mg OD

Tab.OROFER X5 OD

Tab.NODOSIS 500mg BD

Tab.SHELCAL 500mg OD

Tab.BIO D3 0.25mg OD 

Tab.NICARDIA 300mg OD 

Tab.ARKAMINE 0.1mg TID

Tab.PAN 40mg OD

DISCUSSION: