case 44

45year old male 
DOA -1/10/2024
DOD -7/10/2024.
CKD DURATION -3years and is on maintenance hemodialysis since 7months 

Diagnosis
 CKD[STAGE V] 
DELIRIUM UNDER EVALUATION(?UREMIC)- MODERATE ANEMIA SECONDARY TO CKD K/C/O DM II,l HTN,CKD 
S/P 2 PRBC TRANSFUSIONS 

Case History and Clinical Findings
 C/O DECREASED URINE OUTPUT SINCE 4 DAYS 
C/O VOMITINGS SINCE TODAY MORNING 
HOPI
PATIENT WAS APPARENTLY ASYMPTOMATIC 4 DAYS AGO THEN DEVELOPED DECREASED URINE OUTPUT INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE NOT ASSOCIATED WITH BURNING MICTURITION NAUSEA AND GENERALISED WEAKNESS H/O VOMITINGS NON BILIOUS NON PROJECTILE FOOD AS CONTENT N/H/O FEVER COLD , COUGH, ALLERGIES N/H/O ABDOMINAL PAIN , DIARRHOEA N/H/O CHEST PAIN , PALPITATIONS , SWEATING, SOB

 PAST H/O
K/C/O HTN ,DM2,CKD SINCE 3 YEARS ON MEDICATION.
 N/K/C/O , EPILEPSY, THYROID ABNORMALITIES, ASTHMA , TB , CAD, CVA

PERSONAL HISTORY
APPETITE - NORMAL
DIET - MIXED
BOWEL AND BLADDER - REGULAR
NO KNOWN ALLERGIES AND ADDICTIONS
GENERAL EXAMINATION :
PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE.
PALLOR PRESENT, PEDAL EDEMA PRESENT
NO SIGNS OF ,ICTERUS,CYNOSIS,CLUBBING,LYMPHADENOPATHY
TEMP: 98.4 F
BP:140/90 MMHG
RR: 18 CPM
PR: 71BPM
SPO2 98 AT RA
GRBS 125 MG%
SYSTEMIC EXAMINATION:
CVS: S1S2 HEARD. NO MURMURS.
RS: BAE+. TRACHEA- CENTRAL.
P/A: SOFT,NON-TENDER.
CNS: NFND


Investigation
RFT
UREA 283 MG/DL
CREATININE13.3 mg/dl
URIC ACID5.6 mmol/L
CALCIUM7.4mg/dl
PHOSPHOROUS10.7 mg/dL
SODIUM131 mmol/L
POTASSIUM3.4 mmol/L.
CHLORIDE70mmol/L

LFT
 Total Bilurubin0.69 mg/dl
Direct Bilurubin0.19 mg/dl
SGOT(AST)14 IU/L
SGPT(ALT)10 IU/L
ALKALINE PHOSPHATASE147IU/L
TOTAL PROTEINS4.8 gm/dl
ALBUMIN2.8 gm/dl
A/G RATIO1.47

CUE
ALBUMIN++++
SUGARNil
BILE

03/10/24 USG ABDOMEN:
FINDINGS : FEW SUB CENTIMETER CYSTS NOTED IN B/L KIDNEYS
IMPRESSION: BILATERAL GRADE II RPD CHANGES WITH SIMPLE RENAL CORTICAL CYSTS

03/10/24 2D ECHO (COLOR DOPPLER) : IMPRESSION:
MODERATE TR+, NO PAH, TRIVIAL MR+ ; MILD AR+ ;NO RWMA , NO AS/MS , SCLEROTIC AV ;
GOOD LV SYSTOLIC FUNCTION ; GRADE 1 DIASTOLIC DYSFUNCTION+ ; NO LV CLOT


HEMOGRAM 
HB: 6.7 
TLC: 9500 
MCV: 83.3
 MCH 28.9 
MCHC : 34.6 
 PC: 1.96 

s.IRON -61.2
S ferritin -167.2


IMPRESSION: NORMOCYTIC NORMOCHROMIC ANEMIA

INTERVENTIONS
ORAL IRON THERAPY -DAILY TAB.OROFER XT
IV IRON THERAPY -TWICE /WEEK
EPO -YES
EPO DOSING -ONCE/2WEEKS
PRBC TRANSFUSED -2
ADMISSION IN ICU -1 due to pulmonary odema 

Treatment Given(Enter only Generic Name)
FLUID RESTRICTION LESS THAN 1.5 LITRES/ DAY
SALT RESTRICTION LESS THAN 2 GM / DAY
TAB.ZOFER 4MG PO/ SOS
INJ IRON SUCROSE 1AMP IN 100ML NS IV OD ALTERNATE DAY
INJ.EPO 4000IU SCONCE WEEKLY
TAB. LASIX 40 MG PO OD 8 AM
TAB. NODOSIS 500MG PO/BD
TAB.SHELCAL CT PO/OD
TAB. OROFER XT PO/OD
TAB.CINOD 10MG PO/OD
TAB.LASIX 20MGPO/BD
TAB.OLANZAPINE 2.5MG PO/SOS[IF PATIENT IS IRRITABLE]
INJ.HAI S/C TID

Advice at Discharge
FLUID RESTRICTION LESS THAN 1.5 LITRES/ DAY
SALT RESTRICTION LESS THAN 2 GM / DAY
INJ.EPO 4000IU SC ONCE WEEKLY
INJ IRON SUCROSE 1AMP IN 100ML NS IV OD ALTERNATE DAY 
TAB. NODOSIS 500MG PO/BD AT 8AM AND 8PM
TAB.SHELCAL CT PO/OD AT 2PM 
TAB. OROFER XT PO/OD AT 8AM 
TAB.CINOD 10MG PO/OD AT 8AM
 TAB.TELMA 20MG PO/OD AT 8AM
 TAB.LASIX 20MG PO/BD AT 8AM AND 8PM INJ.HAI S/C PREMEAL TID 2U-2U-2U

Follow up at 3months 
HB -8.4
MCV -81.3
MCH -28.9
MCHC -30.1
TLC -5400
PLT -2.1

Follow up at the end of thesis 
HB -8.6
MCV -82.0
MCH -29.1
MCHC -31.0.
TLC -6300
PLT -2.2

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