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63/M with CKD on MHD


MEDICINE CASE DISCUSSION

This is an 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. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

CASE SCENARIO: A 63 year old male came for dialysis

HISTORY OF PRESENT ILLNESS: Patient was apparently normal 3 months ago, then he had c/o dribbling of urine, swelling of arms and legs, facial puffiness, nausea, vomiting, constipation and abdominal discomfort for which he went to a hospital in khamman where investigations were done. 

1/9/2021

RBS: 215 mg/dl

Blood urea: 109 

serum creatinine: 5.3

Uric acid: 8.9

albumin: 3.2

CUE: sugar ++

He was advised admission but he denied and went to NIMS, Hyderabad on 4/9/2021.

He presented with fluid overload, uremic symptoms and MHD was initiated through right femoral access. On examination, fundus showed diabetic retinopathy and USG kidneys showed loss of cd, so patient was declared ESRD and access was changed to right IJV permcath on 13/9/2021. Patient was having scrotal swelling during admission so HRUS scrotum was done and scrotal support advised for the edema.

H/O ulcer over left foot in December 2019, diagnosed as diabetic foot. Amputation of first left big toe done.

In December 2020 H/O SOB grade II since 2 months which progressed to grade III since 5 days, diagnosed as ADHF. CAG was done.

Fistula done on 5/10/2021.


PAST HISTORY: 

He is a known case of DM II since 16 years and on insulin. 

HTN since 3 months and on medication.

CAD since 2019. In December 2020, admission in cardiology for ADHF, S/P CAG advised CABG, but was not done.

EXAMINATION:

Pt is c/c/c

BP: 140/90 mm Hg

PR: 81 bpm

RR: 21 cpm

SPO2: 97% on RA

No Pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.

CVS: S1, S2 heard

RS: BAE +, NVBS +

P/A: soft, non tender

CNS: NAD


PROVISIONAL DIAGNOSIS: CKD ON MHD


INVESTIGATIONS: 


1. ECG 



2. 2d Echo 


3.  USG abdomen 




4. Chest Xray




5. Hemogram 



6. CUE



7. LFT



8. Serum urea

     20/11/2021

     23/11/2021



9. Serum creatinine 

    20/11/2021

    23/11/2021



10. Serum electrolytes 

    20/11/2021

    23/11/2021



11. BT CT 


12. Blood group: A -ve

13. Serum iron



DIAGNOSIS: CKD on MHD with global hypokinesia with HTN, DM II, CAD with herpes zoster S/P critical lower limb ischemia

TREATMENT:

1. Fluid restriction <1.5 L/day

2. Salt restriction <2.4 g/day

3. Tab. LASIX 40 mg PO/BD

4. Tab. SHELCAL - CT PO/OD

5. Tab. OROFER - XT PO/BD

6. Cap. BIO D3 PO/OD

7. Inj. ERYTHROPOEITIN 4000 IU S/C weekly twice 

8. Monitor vitals 

9. GRBS 6th hrly

10. Inj. HAI acc to sliding scale 

8 am -- 4pm -- 8pm







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