Case 45 65 male with vomitings and hiccups since 2 days

Doa 2/7/24

Dod 8/7/24

Diagnosis

ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE (STAGE II)

BENIGN PROSTATIC HYPERPLASIA

SEPTIC SHOCK SECONDARY TO UTI(RESOLVED)

HOSPITAL ACQUIRED PNEUMONIA (LEFT MIDLE LOBE)

K/C/O HTN SINCE 20 YEARSAND DM 2 SINCE 15YEARS

K/C/O CVA SINCE 15 YEARS

Case History and Clinical Findings

CHEIF COMPLAINTS :

C/O HICCUPPS SINCE 3 DAYS

C/O VOMITINGS SINCE 2 DAYS

HISTORY OF PRESENTING ILLNESS :

PT WAS APPARENTLY ASYMPTOMATIC 3 DAYS BACK, THEN HE DEVELOPED HICCUPPS

INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE WITH MULTIPLE EPISODES OF

VOMITINGS WHICH IS NON PROJECTILE,NON BILIOUS,NON BLOOD STAINED.

H/O SLURRING OF SPEECH SINCE 2 DAYS

H/O BED WETTING

NO H/O INVOLUNTARY DEFECATION

H/O HYPONATREMIA

PAST HISTORY :

K/C/O HTN SINCE 20 YEARS, DM II SINCE 15YEARS

H/O AMPUTATION (BELOW KNEE) OF LEFT LOWER LIMB 6 YEARS AGO

N/K/C/O CVA,CAD,TB,EPILEPSY

ON GENERAL EXAMINATION :

PT IS CONCIOUS COHERENT COOPERATIVE AND WELL ORIENTED TO TIME PLACE AND

PERSON.

NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, GENERALISED LYMPHADENOPATHY

VITALS :

TEMP - 98.6 F

PR - 86 BPM

RR - 16 CPM

BP - 100/60 MM HG

SYSTEMIC EXAMINATION -

CVS - S1 S2 HEARD NO MURMURS

CNS - NFND

RS - BAE +, NORMAL VESICULAR BREATH SOUNDS HEARD

P/A - SOFT, NON TENDER, NO ORGANOMEGALY

Investigation

RFT 02-07-2024 05:57:PM

UREA 184 mg/dlCREATININE 7.1 mg/dlURIC ACID 3.9 mmol/LCALCIUM 8.9

mg/dlPHOSPHOROUS 4.6 mg/dlSODIUM 128 mmol/LPOTASSIUM 4.3 mmol/L.CHLORIDE 98

mmol/L

LIVER FUNCTION TEST (LFT) 02-07-2024 05:57:PM

Total Bilurubin 3.10 mg/dlDirect Bilurubin 0.39 mg/dlSGOT(AST) 16 IU/LSGPT(ALT) 12

IU/LALKALINE PHOSPHATASE 260 IU/LTOTAL PROTEINS 5.2 gm/dlALBUMIN 2.88 gm/dlA/G

RATIO 1.24

HBsAg-RAPID 02-07-2024 05:57:PM Negative

Anti HCV Antibodies - RAPID 02-07-2024 05:57:PM Non Reactive

COMPLETE BLOOD PICTURE (CBP) 02-07-2024 05:57:PMHAEMOGLOBIN 6.4 gm/dlTOTAL

COUNT 14900 cells/cummNEUTROPHILS 90 %LYMPHOCYTES 04 %EOSINOPHILS 00

%MONOCYTES 06 %BASOPHILS 00 %PLATELET COUNT 2.65SMEAR Normocytic normochromic

anemia with neutrophilia leucocytosis

RFT 03-07-2024 05:22:AMUREA 120 mg/dlCREATININE 4.7 mg/dlURIC ACID 2.8 mmol/LCALCIUM

10.0 mg/dlPHOSPHOROUS 4.1 mg/dlSODIUM 137 mmol/LPOTASSIUM 4.2 mmol/L.CHLORIDE 106

mmol/L

POST LUNCH BLOOD SUGAR 03-07-2024 09:02:AM 145 mg/dl

RFT 04-07-2024 05:00:AMUREA 69 mg/dlCREATININE 3.3 mg/dlURIC ACID 2.0 mmol/LCALCIUM

10.2 mg/dlPHOSPHOROUS 2.8 mg/dlSODIUM 135 mmol/LPOTASSIUM 4.2 mmol/L.CHLORIDE 104

mmol/L

RFT 05-07-2024 04:55:AMUREA 87 mg/dlCREATININE 4.1 mg/dlURIC ACID 2.5 mmol/LCALCIUM

9.8 mg/dlPHOSPHOROUS 2.5 mg/dlSODIUM 140 mmol/LPOTASSIUM 3.6 mmol/L.CHLORIDE 105

mmol/L

RFT 05-07-2024 11:44:PMUREA 61 mg/dlCREATININE 2.9 mg/dlURIC ACID 2.0 mmol/LCALCIUM

10.1 mg/dlPHOSPHOROUS 2.0 mg/dlSODIUM 139 mmol/LPOTASSIUM 3.3 mmol/L.CHLORIDE 104

mmol/L

BLOOD TRANSFUSION DONE ON 2/7/24 AND 5/7/24 2UNIT PRBC

2D ECHO-

EF-61%

MILD AR+,MILD TR+ WITH PAH,TRIVIAL MR+

NO RDWA NO AS/MS,SCLEROTIC AV

GOOD LV SYSTOLIC FUNCTION

GRADE I DIASTOLIC DYSFUNCTION

Treatment Given(Enter only Generic Name)

1. FLUID RESTRICTION <1.5 L/DAY

2. SALT RESTRICTION <2 G/ DAY

3. INJ. EPO 4000 IU S/C WEEKLY

4. INJ. LASIX 20 MG IV/BD

5. TAB NODOSIS 500 MG PO/BD

6. TAB SHELCAL CT 500 MG PO/BD

7. TAB OROFER XT PO/OD

8.INJ MEROPENEM 500MG IV/BD X4 DAYS

9.INJ.IRON SUCROSE 200MG IV IN 100ML NS

10.INJ.HAI ACCORDING TO GRBS

11.IV FLUIDS 2 UNITS NS @50ML/HR

12.TAB.PCM 650MG PO/BD

13. TAB.TAMSULOSIN 0.1MG PO/HS

1st Dialysis 2/7/24

2nd Dialysis 3/7/24

3rd Dialysis 5/7/24

4th Dialysis 7/7/24

Advice at Discharge

1. FLUID RESTRICTION <1.5 L/DAY

2. SALT RESTRICTION <2 G/ DAY

3. INJ. EPO 4000 IU S/C WEEKLY TO CONTINUE

4. TAB LASIX 40 MG BD TO CONTINUE

5. TAB NODOSIL 500 MG PO/BD TO CONTINUE

6. TAB SHELCAL CT 500 MG PO/BD TO CONTINUE

7. TAB OROFER XT PO/OD TO CONTINUE

8. INJ HAI 4U sc/TID

Follow up in february 2025

Dialysis dependant

Fbs 115 mg/dl

Plbs 158 mg/dl

Hba1c 6.4%