65M with decreased urine output and pedal edema.
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1. Abdominal distension since 1 day
2. Decreased urine output since 2-3 days
3. Shortness of breath at rest since 3 days
4. Bilateral lower limb swelling since 10 days.
Patient was apparently alright 5 years back , then one day he noticed both lower limb swelling till ankle which was on and off and was relieving after work. Then he noticed that his daily routine was slightly improved due to easy fatiguability and tiredness.
After few days his lower limb swelling progressed uptill knee and SOB worsened.
Then in apprehension he consulted near by physician and evaluated for Pedal edema and SOB. Then for the first time he was diagnosed with Both Diabetes and Renal failure.
What a irony..!! Diabetes a preventable disease presenting directly with microvascular complications involving kidney..!! Since then he was treated conservatively. He is currently using inj. Mixtard 35 - X - 25 daily.
1 n half year back with similar complaints of SOB and pedal edema for further work up patient went to NIMS in the hope of light.. kidney biopsy was done and advised for conservative management.
1 year back patient developed a wound on Right foot which was non healing and progressive to involve half of the foot. Debridement was done and wound healing was fasten..
Now patient presented to casuality with complaints of abdominal distension since 2 days associated with pain localised to peri umbilical and lower abdomen, associated with decreased urine output and shortness of breath.
On further questioning patient wife recollected that his he had fever 10 days back which is low grade associated with productive cough with small quantity of sputum and relieved with medication.
Personal history :
Appetite : decreased
Diet : mixed
Sleep : adequate
Bladder : decreased urine output
Bowel movements: regular
Addictions :absent
General examination:
Pallor: absent
Icterus: absent
Cyanosis : absent
Clubbing : absent
Lymphadenopathy : absent
Edema : present B/L pitting type of pedal edema.
Vitals:
Temperature: afebrile
Pulse: 119 bpm
Blood pressure:140/80 mm of hg
Respiratory rate : 28 bpm
SpO2 : 96 on RA
GRBS : 358 MG/DL
Systemic examination:
Cardiovascular system
JVP -raised
Visible pulsations: absent
Apical impulse : left 5th intercostal space in midclavicular line.
Thrills -absent
S1, S2 - heart sounds heard
Pericardial rub - absent
Respiratory system:
Patient examined in sitting position
Inspection:-
oral cavity- Normal ,nose- normal ,pharynx-normal
Chest shape : Barrel
Trachea is central in position.
Palpation:-
All inspiratory findings are confirmed
Trachea central in position
Apical impulse in left 5th ICS,
Chest movements bilaterally symmetrical
AUSCULTATION
Decreased air entry on Rt side
B/L crepts present ( Rt > Lt)
Abdomen examination:
INSPECTION
Shape : distended
Umbilicus:normal
Movements :normal
Visible pulsations :absent
Skin or surface of the abdomen : normal
PERCUSSION- tympanic
AUSCULTATION :bowel sounds heard
USG :
Labs :
Diagnosis:
AKI on CKD 2 to Pneumonia with ?Diabetic nephropathy.
Treatment :
1. Hemodialysis initiated on 19/6/22
2. Inj. AUGMENTIN 625 mg BD
3. Inj. Lasix 40 mg BD
4. Inj. HAL S/C TID acc to GRBS
5. T NODOSIS 500mg BD
6. T. Orofer-XT OD
7. T. Shelcal 500mg PO OD
8. T. Azithromycin 500mg OD
9. T. Met-XL 25 mg OD
Day 2 :
S - decreased urine output and abdominal discomfort and pedal edema
O - Temperature: afebrile
Pulse: 119 bpm
Blood pressure:140/80 mm of hg
Respiratory rate : 28 bpm
SpO2 : 96 on RA
GRBS : 358 MG/DL
B/L IAA crepts
No urine output since today morning
RFT - derranged
A - AKI on CKD 2 to Pneumonia
P - initiated hemodialysis and inj. Augmentin 625mg BD, T. Azithromycin 500mg OD
Indications for dialysis :
1. Uremic encephalopathy
2. No urine output
3. Metabolic acidosis ( pH 7.1, Hco3 - 8.1 )
Day 3 :
Symptoms improved but fever spikes and fever present. Dry cough +
Day 4 :
Fever persisted but cough decreased. No sputum
Day : 5
S - c/o fever and dry cough present
O - pt C/C/C
BP 140/70
PR 110
RR 24
SPO2 - 97 ON RA
TEMP : 101F
Cvs : S1, S2 heard
Rs : BAE + CREPTS DECREASED ON RT SIDE COMPARED TO YESTERDAY.
Counts increase from 9700 to 11.3K
Xray better compared to admission xray.
A - AKI on CKD 2 to Community acquired pneumonia
P - escalated antibiotic from augmentin to piptaz
Day 6
Today's nephrology update :
Amc bed 3
http://drkulkarnimd.blogspot.com/2022/06/65m-with-decreased-urine-output-and.html
S - c/o dry cough present on and off, no fever
O - pt C/C/C
BP 130/70
PR 92
RR 20
SPO2 - 97 ON RA
TEMP : 98.5F
Cvs : S1, S2 heard
Rs : BAE + CREPTS DECREASED ON RT SIDE COMPARED TO YESTERDAY.
Counts increase from 9 11.3K to 12500
Xray better compared to admission xray.
Blood c/s - psudomonas resistant to piptaz
A - AKI on CKD 2 to Community acquired pneumonia
P - changed antibiotics to Clindamycin according to senstivity
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