case 10

Case 10 -70year old female
DOA-8/9/2924
DOA-10/9/2024
Duration of CKD -2years

Diagnosis 
HYPOGLYCEMIA SECONDARY TO OHA'S (RESOLVED)
 CHRONIC RENAL FAILURE (DIABETIC NEPHROPATHY)
 K/C/O HTN, TYPE II DM SINCE 3 YEARS
 COMMUNITY ACQUIRED PNEUMONIA
 S/P 4 SESSIONS HEMODIALYSIS
 1. PRBC TRANSFUSION

Case History and Clinical Findings
PATIENT BROUGHT TO CASULTY IN UNCONSCIOUS STATE C/O DECREASED URINE OUTPUT 2 DAYS C/O PEDAL EDEMA, FACIAL PUFFINESS X 2 DAYS HOPI
PATIENT WAS APPARENTLY ALRIGHT 2 DAYS BACK THEN SHE DEVELOPED URINE OUTPUT , SHE DEVELOPED ANASARCA SINCE 2 DAYS.TODAY AT 2 PM SHE BECAME UNCONSCIOUS AND WAS BROUGHT TO CASUALTY IN AN UNRESPONSIVE STATE FEVER SINCE 3 DAYS A/W CHILLS AND RIGORS COUGH WITH SPUTUM SINCE 3 DAYS, SCANTY
PAST HISTORY

K/C/O DM2 SINCE 3 YEARS ON TAB. GLIMIPERIDE 1 MG 1/2 TAB OD , METFORMIN 500 MG K/C/O HTN SINCE 3 YEARS ON T.CINOD 5MG OD K/C/O CKD SINCE 2 YERAS ON CONSERVATIVE MANAGEMENT USING INHALER SINCE 3 DAYS DUE TO SOB.


PERSONAL HISTORY
APPETITE - DECREASED SINCE 3 DAYS
DIET - MIXED
BOWEL AND BLADDER - CONSTIPATION SINCE 3 DAYS, DECREASED URINE OUTPUT SINCE
3 DAYS
NO KNOWN ALLERGIES
ADDICTIONS-OCCASIONAL ALCOHOL (TODDY) STOPPED 6 MONTHS AGO
GENERAL EXAMINATION :
PALLOR PRESENT, PEDAL EDEMA PRESENT
NO SIGNS OF ICTERUS,CYNOSIS,CLUBBING,LYMPHADENOPATHY

TEMP: 98.7F
BP:150/90 MMHG
RR: 18 CPM
PR: 98 BPM
GRBS: 50 MG/DL
SPO2 98 AT RA
SYSTEMIC EXAMINATION:
CVS: S1S2 HEARD. NO MURMURS.
RS: BAE+. TRACHEA- CENTRAL, B/L BASAL CREPTS PRESENT
P/A: SOFT,NON-TENDER.
CNS: NFND

OPHTHALMOLOGY REFERAL DONE ON 10/09/24 I/V/O DIABETIC RETINOPATHIC CHANGES
FUNDOSCOPY IMPRESSION:
MODERATE NON PROLIFERATIVE DIABETIC RETINOPATHY CHANGES NOTED

ADVICE: STRICT DIABETIC DIET
REVIEW TO OPD EVERY 6 MONTHS
ORTHOPEDICS REFERAL DONE ON 10/09/24 I/V/O ? RIGHT PELVIC FRACTURE
DISGNOSIS : MALUNITED RIGHT IT WITHOUT DNVD

ADVICE:
ADEQUATE PAIN MANAGEMENT
PHYSIOTHERAPY - HIP STRENTHENING EXERCISE
REVIEW TO ORTHO OPD AT DISCHARGE ON TUESDAY/FRIDAY


INVESTIGATION 

HB -6.8
MCV -78.7
MCH-34.2
MCHC-31.7
TLC -7800
PLT-2.85

PERIPHERAL SMEAR -NORMOCYTIC NORMOCHROMIC 

S.IRON-92
S.FERRITIN-168

BLOOD UREA 107 mg/dl
SERUM CREATININE  8.7 mg/dl
SODIUM 134 mmol/L
POTASSIUM 4.2 mmol/L
CHLORIDE 98 mmol/L

LIVER FUNCTION TEST (LFT) 
Total Bilurubin 0.62 mg/dl
Direct Bilurubin 0.15 mg/dl
SGOT(AST) 32 IU/L
SGPT(ALT) 14 IU/L
ALKALINE PHOSPHATASE 339 IU/L
TOTAL PROTEINS 5.6 gm/dl
ALBUMIN 3.27 gm/dl
A/G RATIO 1.34
COMPLETE URINE EXAMINATON
ALBUMIN +++
SUGAR Nil
PUS CELLS 3-4
EPITHELIAL CELLS 2-3
RED BLOOD CELLS Nil


USG ABDOMEN
RT KIDNEY 8.6X4.4 CM LT KIDNEY 8.9X5.1 CM
IMPRESSIONB/L GRADE-II RPD CHANGES, LEFT RENAL CORTICAL CYST

2D ECHO -
EF -57%
GRADE 1 DIASTOLIC DYSFUNCTION 
LVH +

INTERVENTIONS
ORAL IRON THERAPY -DAILY TAB.OROFER XT
IV IRON THERAPY -TWICE /WEEK
EPO -YES
EPO DOSING -ONCE/WEEK
PRBC TRANSFUSED -YES 1PRBC
ADMISSION IN ICU -0

 TREATMENT GIVEN 

 FLUID RESTRICTION LESS THAN 1.5 LITRES/DAY
SALT RESTRICTION LESS THAN 1.5G/DAY
 INJ. LASIX 40MG IV/TID
INJ.EPO 4000IU S/C TWICE DAILY 
INJ. IRON SUCROSE 100 MG IV/OD
 TAB. NODOSIS 500MG PO/BD
 TAB. CINOD 100 MG PO/OD 
TAB. SHELCAL CT PO/OD
Tab. PAN 40 MG IV/OD
SYP . ASCORYL LS/70 ML PO TID
GRBS 2ND HOURLY
 STRICT I/O 

Advice at Discharge
FLUID RESTRICTION LESS THAN 1.5 LITRES/DAY
 INJ.EPO 4000IU S/C WEEKLY ONCE 
 SALT RESTRICTION LESS THAN 1.5 G/DAY TAB. NODOSIS 500MG PO/BD X 20 DAYS
 TAB. CINOD 10MG PO/OD 
TAB.TELMA 20MG PO/OD
TAB. SHELCAL CT PO/OD X 20 DAYS
 


FOLLOW UP AFTER 3MONTHS 
HB-8.0
MCV-78.7
MCH -34.2
MCHC-31.7
TLC -7800
PLT -2.85

AT THE END OF APRIL - PATIENT EXPIRED AT HOME - ? UNKNOWN 

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