PATIENT CAME WITH C/O PEDALEDEMA , DECREASED URINE OUTPUT VOMITING, SHORTNESS OF BREATH AND FACIAL PUFFINESS

Case history and clinical findings:-

PATIENT CAME WITH C/O PEDALEDEMA SINCE 6 MONTHS , DECREASED URINE OUTPUT SINCE 1 MONTH , VOMITING SINCE 10 DAYS , SHORTNESS OF BREATH AND FACIAL PUFFINESS SINCE 2 DAYS PATIENT WAS APPARENTLY ASYMPTOMATIC 8 MONTHS BACK THEN HIS STARTED DEVELOPING HYPOGLYCEMIC EPISODES 2 TO 3 TIMES A WEEK AND DURING THE EPISODE , PATIENT BEHAVED VIOLENTLY AND HAD ALTERED SENSORIUM ( ACCORDING TO ATTENDERS ) , VISITED LOCAL PRACTIONER AND PATIENT WAS GIVEN 25D , SUGAR LEVELS IMPROVED. PATIENT DEVELOPED PEDAL EDEMA 7 MONTHS AND REPEATED EPISODES OF HYPOGLYCEMIA , DIAGNOSED WITH CKD , TREATED CONSERVATIVELY ,. PATIENT COMPLAINING OF DECREASED URINE OUTPUT SINCE LAST 1 MONTH , COMPLAINTS OF VOMITING SINCE LAST 10DAYS , NON PROJECTILE , NON BILIOUS , FOOD PARTICLE AS CONTENT , NON BLOOD TINGED . C/O SOB SINCE 2 DAYS ( GRADE 2 ) ,RELIEVED ON TAKING REST , C/O FACIAL PUFFINESS SINCE 2 DAYS K/C/O DM TYPE 2 SINCE 15 YEARS , ONINJ MIXTARD , K/C/O HTN SINCE 3 YEARS , ON TAB AMLODIPINE 10 MG, K/C/O TB 3 YEARS BACK , K/C/O CKD SINCE 6 MONTHS ,N/K/C/O HYPOTHYROIDISM , HYPERTHYROIDISM , CVA, CAD , EPILEPSY , ASTHMA


BRIEF COURSE IN HOSPITAL : PATIENT WAS ADMITTED ON 9/7/23 WITH COMPLAINTS OF PEDAL EDEMA SINCE 6 MONTHS,DECREASED URINE OUTPUT SINCE 1 MONTH ,VOMITINGS SINCE 10 DAYS , SHORTNESS OF BREATH AND FACIAL PUFFINESS SINCE 2 DAYS, AFTER 1ST SESSION OF DIALYSIS PATIENT WAS DROWSY,SLURRING OF SPEECH, MRI WAS DONE WHICH SHOWED SMALL VESEL ISCHEMIC CHANGES IN BILATERAL PERIVENTRICULAR REGION. AND NO SIGNS OF RAISED INTRACRANIAL TENSIOJN. SHIFTED TO ICU,AFTER 3RD SESSION OF DIALYSIS PATIENT HAS IMPROVED , PATIENT WAS REFERRED TO THE DEPARTMENT OF OPHTHALMOLOGY ON 13/7/23 FOR FUNDUS EXAMINATION I/V/O RAISED ICT AND DIABETIC RETINOPATHY CHANGES. IMPRESSION: ON FUNDUS EXAMINATION,BOTH EYES SHOWS NO CHANGES OF RAISED ICT FEATURES AND DIABETIC RETINOPATHY.


GENERAL EXAMINATION 

PT IS C/C/C 

NO PALLOR , ICTERUS ,CYANOSIS , CLUBBING , LYMPHADENOPATHY , EDEMA 

TEMP: AFEBRILE

 PR - 102BPM 

BP - 160/100MMHG

 RR - 26 CPM 

GRBS : 222 MG/DL 

SPO2 - 99% AT RA

SYSTEMIC EXAMINATION:

 CVS -:S1S2 + 

RS : BAE + 

CNS : 

TONE RT LT 

UL N N 

LL INCR INCR 

POWER

 UL 5/5 5/5

 LL 5/5 5/5


REFLEXES BI TRI SUPI KNEE ANKLE PLANTAR

 RT ++ - + + + FLEXOR 

LEFT ++ - + + + + FLEXOR 

GCS 15/15


PROVISIONAL Diagnosis:

 AKI ON CKD,DYSELECTROLYTEMIA , HYPONATREMIA RESOLVED , HYPOKALEMIA RESOLVING ?METABOLIC ENCEPHALOPATHY WITH MYOCLONIC JERKS , ? DIALYSIS DYSEQUILIBRIUM SYNDROME RESOLVING , WITH DIABETIC NEPHROPATHY


Investigation

 CBP ( 9/7/23 ) 

HB 7.4 

TC 7500

 N 78 

L 16

 E 1 

M 5 

B 0 

PLT 3.19 

SMEAR MICROCYTIC HYPOCHROMIC

 RFT 

UR 98

 CR 7.3

 UA 5.1

 CA+2 7

 P 4.9

 NA+ 124

 K+ 3.2

 CL- 90

 HIV NON REACTIVE

 HBSAG NON REACTIVE 

HCV NON REACTIVE


Treatment Given

INJ EPO 4000 IU SC ONCE A WEEK

 INJ HAI SC TID 

INJ CLINDAMYCIN 600 MG IV TID

INJ PIPTAZ 2.25 GM IV TID 

INJ SODIUM VALPROATE 500 MG IV BD

 TAB AMLODIPINE 10 MG RT /OD 

TAB OROFER XT RT/OD 

TAB SHELCAL CT RT/OD 

SYRUP POTCHLOR 15 ML RT/TID

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