50 year old female with complaints of pedal edema, shortness of breath and fever.
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50 year old female from Nilavanuru Mandal ( 60 kms from here) was a farmer by occupation. She stopped going to work from last year after her cataract surgery about 8 months ago
H/o cataract surgery : right eye 3 years ago , left eye 8 months ago.
She got married when she was 12 years old . She had 5 children of which 3 are female and 2 are male. All the births were normal vaginal deliveries after which she underwent a hysterectomy ( 20 years ago) .
8 years later she went to hospital in view of fever , got routine investigations done and then they were told that her kidney function has decreased . Used medication for 3 months and stopped. Later the patient didn't follow up.
3 months ago patient developed bilateral pedal edema and facial puffiness for which she was taken to a local hospital where they were told that she has renal failure and sepsis. Patient used medication but pedal edema didn't subside .
Then patient visited kamineni on 22-01-2020 with complaints of fever , pedal edema and shortness of breath since 10 days . Got admitted.
Fever was low grade , intermittent , not associated with headache , vomitings and loose stools.
Pedal edema was of pitting type extending upto knee.
Shortness of breath grade 2-3 acc to NYHA classification . No h/o orthopnea, PND, palpitations , chest pain. No h/o cough .
ON EXAMINATION :-
Patient is in altered mental sensorium since yesterday night with irrelevant speech . She is non coherent. GCS - E4 V3 M5
C/o decreased urine output since 2 days (50 ml) .
Vitals :- BP - 110/70 mmhG
PR - 84 bpm
CVS - S1 S2 heard.
RS - BAE present , Bilateral fine crepts present in ISA , IAA , MA
*Examination findings on 27-01-2021
Pt conscious , and non cooperative ,agitated.
Irrelevant speech present and childish talk present.
Talking on her own and using abusive language , crying in between .
Oriented to place and person but not time.
Complaints of severe back pain and body pains
RS - Bae present and fine crepts present in left IAA
CNS - pupils bilateral reacting to light .
Power -5/5 in bilateral UL and LL.
TONE - normal'
Reflexes- R. L
Biceps 2+ 1+
Triceps 1+ 1+
Supinator -. -
Knee. 2+. couldn't be done due to pain.
Ankle. -. -.
Plantars Bilateral flexion.
No neck stiffness but kernigs sign is positive.
But pt is having low back ache and osteoarthritis of knee joint.
Pt has history of fall from bed ,and pain in left knee joint with minimal swelling. Unable to flex her left knee joint.
No history of fever since admission.
History of low grade fever present 10 days back.
No headache and vomitings.
Pt k/c/o alcoholic 180ml of whiskey ,toddy daily,but stopped 3 months ago according to attenders.
Rft - urea -. 110--- 97 Creat - 5.3---3.2 reduced
Na- 137 K-. 5.2 CL- 106C
Cbp-hb - 7.7 .Tlc reduced from 33,000 to 23,200 PLT - 4.4 lakhs
Abg -ph- 7.17 ;pco2- 18 ; po2- 51.6
Hco3-9
I/O - 1200/1900
Ct Brain - No focal brain leisons.
12*10mm extra axial bone density leison noted in left frontal region - ? BENIGN OSTEOMA.
Altered sensorium secondary to ? Metabolic encephelopathy ( sepsis / uremia / ? Meningitis)
Or Delirium secondary to alochol withdrawal.
*Examination findings on 28-01-2021
50 yr old female with Aki on CKD.
With uremic encephalopathy .
Pt was put central line and taken for one session of hemodialysis yesterday evening according to ramulu sir orders.
As urea creat yesterday were increased - Urea - 139
S creat -6.3 mg/dl and in view of
Refractory metabolic acidosis pt was taken for hemodialysis. with ph-7.13 ,pco2-17
Po2- 115
Hco3- 9
Pt consciousness improved.
Pt c/o severe back and knee pains.
Oriented to time,place ,person.
Bp- 110/70
Pr-84
Spo2- 98% on RA
Cvs - S1S2 present
RS - Bae +
B/l fine crepts present in ISA,ISA.
I/O - 1800ml/1600ml
28/1/21 -
Cbp-hb -8.2 ; Tlc - 21,400
Plt - 4.74
Rft-Urea - 73 , creat - 3.8
Na - 142 ,k-4.6; cl- 101
Abg - Ph- 7.33
Pco2-26
Po2- 77
Hci3-16.1
Plan - Removed ryles tube . Allowing feeds orally.
Conservative management.Plan for xray of left knee joint.
*Examination findings on 29-01-2021
S - Pt sensorium improved.
Oriented to T/P/P
O- BP - 130/80 mmHg
PR - 92bpm
Spo2- 96 %on ra
Cvs - S1S2 present
RS - BAE present.
B/l fine crepts present IAA,ISA.
A - AKI on CKD WITH Uremic encephalopathy (resolving )
Metabolic acidosis - resolved.
Plan - Pt currently is in hemodialysis.
Monitoring her vitals.
*PROVISIONAL DIAGNOSIS *
AKI secondary to urosepsis
AKI on CKD
Metabolic acidosis with hyperkalemia with uremic encephalopathy.
1) fluid restriction to less than 1.5 L per day
2) salt restriction less than 2g per day
3) Injection PIPTAZ 4.5 g IV Stat to Inj PIPTAZ 2.25 g IV TID
4) Injection ZOFER 4mg IV TID
5) T. OROFER XT BD
6) T. SHELCAL 500mg OD
7) ryles feeding milk with protein powder and free water 4th hourly.
8) IVF NS - U.O + 30 ml / hr
9) BP , PR charting, SpO2 charting - 4th hourly
10) Temp charting 4th hourly
11) GRBS charting 6th hourly.
Planning for hemodialysis.
