A 50 yr old man with " Diabetes for 10 years and azotemia for 3 years "
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Case presentation:
A 50 yr old Male who owns a laundry shop was apparently asymptomatic 3 yrs back,
Then had vomitings ( episodes and character records not available )for which he went to a local hospital where the treating physician observed elevated creatinine levels. So he referred the patient to nephrologist where the repeat creatinine levels showed upto 9 and by then patient was in altered behaviour (irritable and walking here and there). The patients attenders were counselled by the nephrologist to get hemodialysis done( the records of hemodialysis and nephrology consultancy were not available). Accordingly hemodialysis was done and patient was discharged with creatinine upto 5. He was started with nodosis 500mg and metxl 50mg. Since then his creatinine levels were maintained between 2 -3.
Then 50 days back patient had low grade fever with excessive sweating for which he went to a local RMP where his blood pressure checked, it was 160/100. Upon the advice from RMP the tablet metxl was stopped and telma H was started. Patient went to local physician in view of fever where he was diagnosed with typhoid fever and his creatinine levels was 1. He was put on IV antibiotics for 3 days then followed by oral antibiotics for 1 week and telma H for 10 days.
After 1 week patient went to his routine consultancy for nephrologist where the serum creatine levels were found upto 5. The dosage of tab nodosis was increased from 500 to 1000 mg and tab metxl 50mg was restarted.
After using those medications for few days,the patient developed bilateral pedal edema. Then patient attenders called up nephrologist and had explained about patient condition. The doctor advised to decrease the dosage of nodosis from 1000mg to 500mg and also tab lasix 40mg was started which was stopped after his pedal edema got resolved.
Then from 20 days patient complained of difficulty in swallowing and regurgitation of food. Patient also complained of burning sensation in chest. At this time eventhough pt had these complaints, he did his routine activity on his own. After 3- 4 days the patient had weakness in all extremities and he started taking help of his son for his routine activity.
Patient was brought to KIMS with chief complaints of generalized weakness and drowsiness.
Past history:- known case of DM type 2 since 10 years (glymi 1 and glymi 2) and HTN since 10 year(metxl).
No h/o any previous blood transfusions and surgeries.
FAMILY HISTORY :No H/O similar complaints in the family
PERSONAL HISTORY:
He was on mixed diet, appetite normal, bowel and bladder habits regular and occasionally toddy drinker (since 30 years, approx 250ml)
GENERAL EXAMINATION:
On presentation pt was drowsy.
no Icterus,cyanosis,clubbing, lymphadenopathy,edema
VITALS:
Temperature-99.8°f on presentation
BP:130/90mmhg
PULSE:84bpm
RR:24cpm
Spo2:98%
GRBS:120mg/dl
GCS: E4 V5 M5(14/15)
Systemic examination:-
CVS- s1 s2 heard,no murmurs
PER ABDOMEN-
Scaphoid in shape, no palpable mass present.Hernial orifices are free. Liver and spleen are not palpable. Bowel sounds are present.
CNS-
Higher mental function- cannot be assessed.
Motor system:
Power- cannot be assessed
Tone - hypertonic
Reflexes- absent
Cranial nerves and sensory examination could not be assessed.
RESPIRATORY SYSTEM -bilateral air entry present , + normal vesicular breath sounds. no added sounds
Investigations:-
Hemogram
Diagnosis:- Acute kidney injury with primary respiratory alkalosis with hyponatremia, hypokalemia and hypochloremia .
Treatment:-
1)Infusion 3%Nacl 100ml over 15 mins bolus.
2)Infusion 3% Nacl @ 45ml/hr.( To infuse 750ml(7mmol/l) over 16-18 hrs)
3)Infusion kcl 6amp in 1L 0.9% Nacl over 6 hrs.
4)Inj.HAI s.c TID according to sliding scale.
5)Absolute free water restriction
Day 2:-
No fresh complaints
Investigations:-
Hemogram
Treatment:-
1) Inj 3% Nacl @ 50ml/hr infusion
2) Inj Kcl 4amps in 1 litre of 5%dextrose over 6 hours
3) serum sodium every 4th hourly
4) Inj HAI s/c TID according to sliding scale
5) Ryles tube feeding 4th hourly with milk(with teaspoon of salt)
Day 3:-
No fresh complaints
Investigations:-
Blood sugar- fasting
Treatment:-
1) Inj. 3% Nacl @50ml/hr I.v infusion
2)Ryles tube feeding with every 4th hrly with milk( teaspoon of salt)
3)Inj. HAI sc tid acc to sliding scale.
