CASE OF A 60 YEAR OLD MALE WITH CKD

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April 23, 2021

CASE OF A 60 YEAR OLD MALE WITH CKD

This is the case i have been given :

A 65 year old male who was a farmer came to the OPD with

 CHIEF COMPLAINTS OF :

1. Decreased urine out since 4 months

2. Bilateral pedal edema since 4 months and 

3. Abdominal distension since 4 months

HISTORY OF PRESENT ILLNESS : 

Patient was apparently asymptomatic 4 months back then developed decreased urine output , which is insidious in onset with decreased frequency and later facial puffiness followed by bilateral pedal edema , pitting type, gradually progressed to involve abdomen with abdominal distension, no aggregating and relieving factors. 

There is history of pruritus and pigmentation of both the lower limbs

PAST HISTORY : 

He was k/c/o HTN since 5 yrs and was on medications

No h/o suggesting DM, CAD, CVA, TB, asthma, epilepsy

10 yrs back patient had a road Traffic accident for which surgery(? Intramedullary nail insitu) was done for ?hip fracture In nalgonda govt hospital. He had taken NSAIDS for 1 year then.

4yrs back he developed perforation in tympanum and later progressed to hearing loss

1 year back patient gives history of taking NSAIDS 3 tabs per day daily for bilateral knee and back pain given by RMP. He took it daily for 1 year

He gives a history of cataract surgery for right eye 10years ago

FAMILY HISTORY : 

No k/c/o HTN,DM,TB, asthama,CAD, epilepsy and CKD

PERSONAL HISTORY :

Mixed diet

Appetite is reduced

Sleep is adequate

Bowel regular

Oliguria since 4 months

Addictions : h/o beedi smoking 4-5 years ,stopped 1 year back

GENERAL EXAMINATION :

• Patient is conscious, coherent & cooperative 

• Thin built and malnourished

GENERAL SIGNS :

• PALLOR present

• No Icterus, cyanosis,clubbing koilonychia and Lymphadenopathy 

PEDAL EDEMA + , which is pitting type

VITALS :

• Temp: 98.5 F,

• RR : 18 cycles/min,

• BP : 100/70mmHg,

• PR : 80/min, regular rythm, normal volume,no radio-radial or radio-femoral delay, Condition of the vessel wall is normal

• SpO2: 97% on RA

SYSTEMIC EXAMINATION :

• CVS: s1 s2 +

 no murmurs

• RS:

Bilateral air entry present

Normal vesicular breath sounds, No added sounds

• CNS:

1)Intellectual functions

 -patient is conscious,oriented to time ,place and person

-memory-immediate,recent and remote memory present

-appearence-well kept

-speech-normal 

2)cranial nerves

Olfactory-smell present on both sides

Optic-visual acuity -6/6

    Visual field,colour vision,reflexes -normal 

3,4,6 cranial nerves-ocular movements -present

         Nystagmus,pros is,Diplopoda-absent

       Pupils are normal

Trigeminal -motor and sensory functions normal on both sides

 Facial nerve

-No deviation of mouth 

-frowning present

-absent nasolabial folds on left side

-blowing and whistling absent

Taste sensation on anterior 2/3rd of tongue present

Corneal reflexpresent on both sides

Vestibulocochlear nerve-rinnes Weber,schwabach test Negative on both sides

Vagus and glossopharyngeal -uvula midline

Spinal accessory-shrugging of shoulders present

Hypoglossal-no deviation of tongue

3)Motor system

A)attitude and position-Normal

B)bulk-no wasting

C)tone-Rt Lt

UL N N

LL N N

D)power-

UL Rt Lt

      -5/5 -5/5

LL -5/5 4/5

4)Reflexes

Superficial Rt Lt

  Corneal +2 +2

 Conjunctival +2 +2

Abdominal +2 +2        

Deep Rt Lt

Biceps +2 +3

Triceps +2 +2

Supinator +2 +2

Knee +2 +2

Ankle 0 0

5)Sensory system  

Superficial -fine touch,temperature,pain -present

Deep-position,vibration,crude touch,stereognosis,2point discrimination- present 

6)Cerebellum 

Speech,nystagmus,ataxia,tremors,released reflexes absent

7)Coordination and gait

Finger nose test ,finger finger test,heel knee test-present

Gait -dragging type

 Romberg test -negative

8)signs of meningeal irritation

Nuchal rigidity,kernigs and brudzinski’s sign - absent

• Per abdomen :

Soft

Non tender

No organomegaly

Bowel sounds heard

INVESTIGATIONS :

Complete blood picture

Complete urine examination

TREATMENT GIVEN :

The patient was on hemodialysis along with drugs

Hemodialysis chart

Fluid & salt retention (< 1 litre/day and <2gm/day )

Tab. Nicardia 10 mg TID

Tab. Lasix 40 md BD

Tab. Nododis 500 mg BD

Tab. Shelcol OD

CAP - alpha -D3 OD

Sodium bicarbonate

Injection iron sucrose 100 mg BD

Injection Monocef 1g BD

Injection erythropoietin 4000 iu/ one weekly