A 65 YEAR OLD MAN WITH BILATERAL PEDAL EDEMA AND DECREASED URINE OUTPUT

FINAL PRACTICAL- LONG CASE:

HT NO: 1701006192

A 65 year old male, resident of Bhongiri and a Toddy tree climber by occupation, came to the OPD with chief complaints of:

• Loss of appetite since one week
• Swelling of the lower limbs since 4 days
• Decreased urine output since 4 days

Daily routine:

Patient is a toddy tree climber, wakes up early in the morning at around 5:30 am and goes for work after having breakfast. He comes back for lunch and again goes back to work. He has stopped working  4 years ago because of backpain.

HISTORY OF PRESENTING ILLNESS:

On Day 1:

Patient was apparently asymptomatic 4 years ago, when he developed knee pains and generalized weakness, for which he went to a local hospital, and was given some medication. The pains occured on and off for about 3 years and most recently patient complained of backache 2 months ago radiating towards the right lower limb,  and hence MRI SPINE was taken, which showed L4 - L5 spondylolisthesis with mild sclerosis, and was advised to take analgesics ( cox-2 inhibitors and paracetamol), Multivitamins and calcitriol.

Presently, patient complains of loss of appetite, decreased urine output and bilateral pedal edema of grade 1 since 4 days.

Patient also complains of 3 episodes of vomitings,  2 days ago which were watery, non- bilious , non- blood stained, non - foul smelling and non projectile.

No h/o fever , abdominal pain, headache

PAST HISTORY:

There were no similar complaints in the past.

Patient is a known case of Hypertension and is on medication for the same 

Patient is not a known case of Diabetes mellitus, Bronchial Asthma, T.B, epilepsy and CAD

FAMILY HISTORY:

Insignificant

PERSONAL HISTORY:

DIET- Mixed

APPETITE- Reduced since one week

BOWEL AND BLADDER MOVEMENTS-

Decreased urine output since 4 days

Patient complains of watery stools since 2 days

SLEEP- Adequate

ADDICTIONS - Patient is an occasional alcohol consumer and smokes 10 beedis per day since 40 years

Stopped 6 months ago

No known allergies

GENERAL EXAMINATION:

Patient was examined in a well lit room, with prior consent and adequate exposure.

He is conscious, coherent and co-operative.

He is well oriented to time, place and person.

He is moderately built and moderately nourished.

Bilateral grade 2 pedal edema was present on Day 1 of admission. Now it has reduced.

No signs of pallor, icterus, clubbing, cyanosis, and lymphadenopathy.

VITALS:

Patient is Afebrile

Respiratory rate: 20cpm

Pulse : 80bpm

Blood pressure: 140/70 mm of Hg.

SpO2 : 96 % 

SYSTEMIC EXAMINATION:

CVS: S1, S2 heard. No raised JVP

No murmurs were heard.

CNS: 

Conscious 

Speech normal

Cranial nerves : Intact

Motor system: normal

Sensory system :Normal

Reflexes normal

No focal abnormality detected

RESPIRATORY SYSTEM: Bilateral air entry present with normal vesicular breath sounds.

PER ABDOMEN: 

Scaphoid in shape 

Mild tenderness present in right lower lumbar region, otherwise normal and soft

Bowel sounds are present.

INVESTIGATIONS:

On Day 1:

Blood-

Hb: 11.2

TLC: 6700

Platelets: 1.82

RBC: 3.37 million

RBS: 92

Urea : 149 mg/dl

Creatinine: 9.9 mg/dl

Na: 138

Ca: 9.5

Phosphate: 4.9

K: 4.4

Cl: 106

CUE- Normal

ABG:

pH-7.2

HCO3- 10.1

PO2- 84

PCO2- 22.3

SpO2-  94.8

Serum Fe- 79

Serology- Negative

LFT-

TB: 0.99 mg/dl

DB: 0.2 mg/dl

AST: 14 IU/L

ALT: 10 IU/L

ALP: 88 IU/L

Total Protein-5.6 g/dl

Albumin: 3.46 g/dl

ECG:

X-ray : On 11/6/22

On 10/6/22:

Ultrasound Abdomen-

• Bilateral Grade 1 RPD changes with simple renal cortical cysts (Few cystic lesions located in B/L kidneys, largest being 2.7 * 2cm in upper pole of right kidney and 2.3 *2.2 cm in upper pole of left kidney)
• Supraumbilical hernia with omentocoele

2D-Echo:

• Mild diastolic dysfunction
• Mild Left Ventricular Hypertrophy
• No systolic dysfunction
• No Mitral regurgitation
• No Pulmonary artery Hypertension and pulmonary embolism
• No Regional wall Motion Abnormalities

PROVISIONAL DIAGNOSIS:

AKI on CKD with polycystic kidney disease.

TREATMENT:

Hemodialysis done on Day 1 

ON DAY 2:

Patient is c/c/c

Pulse - 80 bpm

Bp- 110/70 mm of Hg

RR- 20 cpm

SpO2- 98

Grbs- 96 mg/dl

I/O - 900/ 150 ml

Cvs - S1 S2 heard, no murmurs

Respiratory system- BAE+, NVBS

Cns- NFAD

Per abdomen - soft, non tender

TREATMENT GIVEN:

• Tab. Lasix 40 mg / PO/ BD
• Tab. Nodosis 500 mg PO/OD
• Tab. Pantop 40mg PO/ BD
• Tab. MVT PO / OD
• Tab. Shelcal 500 mg PO/ OD
• BP/ temperature/ pulse rate/ Urine output monitoring every 4th hourly.
• GRBS every 12th hourly.
• Salt and fluid restriction.

On Day 3:

Patient is c/c/c

Pulse - 110 bpm

Bp- 100/70 mm of Hg

RR- 19 cpm

SpO2- 98

Grbs- 96 mg/dl

Cvs - S1 S2 heard, no murmurs

Respiratory system- BAE+, NVBS

Cns- NFAD

Per abdomen - soft, non tender.

I/O : 700/350 ml

Blood urea : 129 mg/dl

Sr. Creatinine : 8.4 mg/dl

Na: 138

K: 3.7

Cl: 99

TREATMENT GIVEN:

SECOND ROUND OF HEMODIALYSIS DONE

• Tab. Lasix 40 mg / PO/ BD
• Tab. Nodosis 500 mg PO/OD
• Tab. Pantop 40mg PO/ BD
• Tab. MVT PO / OD
• Tab. Shelcal 500 mg PO/ OD
• BP/ temperature/ pulse rate/ Urine output monitoring every 4th hourly.
• GRBS every 12th hourly.
• Salt and fluid restriction.

On Day 4:

Patient is c/c/c

Pulse - 92 bpm

Bp- 110/70 mm of Hg

RR- 18 cpm

SpO2- 98

Grbs- 97 mg/dl

Cvs - S1 S2 heard, no murmurs

Respiratory system- BAE+, NVBS

Cns- NFAD

Per abdomen - soft, non tender.

TREATMENT GIVEN:

IV FLUIDS- NS @UO + 30ml/hr

Tab. Lasix 40 mg / PO/ BD

Tab. Nodosis 500 mg PO/OD

Tab. Pantop 40mg PO/ BD

Tab. MVT PO / OD

Tab. Shelcal 500 mg PO/ OD

BP/ temperature/ pulse rate/ Urine output monitoring every 4th hourly.

GRBS every 12th hourly

Salt and fluid restriction.