case 28

53year old female 
DOA -17/01/2024
DOD -28/02/2024
CKD DURATION -7months and on maintenance hemodialysis since 7months

DIAGNOSIS -
STAGE 5 CHRONIC KIDNEY DISEASE ON MAINTAINENCE HEMODIALYSIS
 T2 DM+ AND HTN+


Case History and Clinical Findings 
C/O FACIAL PUFFINESS SINCE 1 MONTH C/O PEDAL EDEMA SINCE 1 MONTH HOPIPT WAS APPARENTLY ASYMPTOMATIC 1 MONTH BACK THEN SHE DEVELOPED FACIAL PUFFINESS AND PEDAL EDEMA , INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE, WITH SOB GRADE III FOR WHICH SHE USED OUTSIDE MEDICATION AND WAS PARTALLY RELIEVED , THEN SINCE 4 DAYS SYMPTOMS GOT AGGRAVATED. SINCE 1 DAY, DECREASED URINE OUTPUT, FEVER, COUGH WITH EXPECTORATION LOW QUANTITY.

PAST HISTORY
K/C/O DM SINCE 5 YRS
 K/C/O HTN SINCE 1 YR
NOT A K/C/O CVA, CAD, EPILEPSY, TB, THYROID DISORDERS 

GENERAL EXAMINATION
PT IS C/C/C
NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY. PALLOR+
PEDAL EDEMA+ 
TEMP- 98.4F
PR-86BPM
BP-140/80MMHG
RR-18CPM
SP02-98% AT RA
SYSTEMIC EXAMINATION-
CVS:S1 S2 +, JVP+
RS:BAE+, B/L BASAL CREPTS+
P/A:SOFT NON TENDER
CNS : NFND
Investigation

LFT
Total Bilurubin 0.6 mg/dl
Direct Bilurubin 0.18 mg/dl
SGOT(AST)33 IU/L
SGPT(ALT) 37 IU/L
ALKALINE PHOSPHATASE 256 IU/L
TOTAL PROTEINS 6.0 gm/dl
ALBUMIN 3.3 gm/dl

RFT 
UREA 158 mg/dl
CREATININE 6.6 mg/dl
URIC ACID 6.7 mg/dl
CALCIUM 9.4 mg/dl
PHOSPHOROUS 6.0 mg/dl
SODIUM 136 mEq/L
POTASSIUM 5.3 mEq/L
CHLORIDE 101 mEq/L



HAEMOGLOBIN 8.8gm/dl
MCV -94
MCH -30
MCHC -32.2
TOTAL COUNT 9600 cells/cumm
PLATELET COUNT 2.04

S iron -44
S.ferritin-380.3

SMEAR Normocytic normochromic anemia

USG
IMPRESSION- B/L RENAL CORTICAL CYSTS
B/L MODERATE PLEURAL EFFUSION
B/L KIDNEYS SHOW RAISED ECHOGENECITY


2D ECHO
MODERATETR+ WITH PAH,MODERATE AR+,MODERATE MR+
NO RWMA, NO AS/MS, SCLEROTIC AV
EF 62%, GOOD LV SYSTOLIC FUNCTION
DFILATED CHAMBERS
MILD CONCENTRIC LVH
MINIMAL PE, NO LV CLOT
NO DIASTOLIC DYSFUNCTION, NO LV CLOT

INTERVENTIONS
ORAL IRON THERAPY -DAILY TAB.OROFER XT
IV IRON THERAPY -THRICE /WEEK
EPO -YES
EPO DOSING -ONCE/WEEK
PRBC TRANSFUSED -1
ADMISSION IN ICU -1 ( due to pulmonary odema)


Treatment Given(Enter only Generic Name)
FLUID RESTRICTION LESS THAN 1.5 LIT/DAY
SALT RESTRICTION LESS THAN 2 GM/DAY
T.NICARDIA 20 MG PO/TID
T.TELMA 40MG PO/OD
T.OROFER XT PO/OD 
T. ARKAMINE 0.1 MG PO/BD
 T.FUROSEMIDE 80MG PO/BD
 T.SHELCAL CT PO/OD
INJ IRON SUCROSE 100MG IV/ONCE IN 2 WEEKS INJ. EPO 4000 IU SC ONCE IN 2 WEEKS


Follow up at 3months 
HB -7.1
MCV -87.6
MCH -29.8
MCHC -31.3
TLC -11700
PLT -3.2

Follow up at the end of thesis 
HB -9.9
MCV -87.8
MCH -29.1
MCHC -30.9
TLC -10800
PLT -2.98

 Advice at Discharge
FLUID RESTRICTION LESS THAN 1.5 LIT/DAY SALT RESTRICTION LESS THAN 2 GM/DAY T.NICARDIA 20 MG PO/TID
 T.TELMA 40MG PO/OD
 T.OROFER XT PO/OD 
T. ARKAMINE 0.1 MG PO/BD
 T.FUROSEMIDE 80MG PO/BD
 T.SHELCAL CT PO/OD
INJ IRON SUCROSE 100MG IV/ONCE IN 2 WEEKS INJ. EPO 4000 IU SC ONCE IN 2 WEEKS

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