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64F with htn ckd denovo dm2 altered sensorium

Sathamma
202422642

Chief complaints:-
This is a case of ,64 yr old female from chinnasuraram who is agricultural and daily wage labourer by occupation brought to casualty with chief complaints of Breathlessness since 20days.
Decreased Urinary output since 10 days.
Fever since 5 days.
History
Patient was born and brought up in chinnasuraram living with her sibling.she is illiterate and started her occupation as daily wage labourer at the age of 10 years she lead a healthy childhood and at the age of 13 years she got married to her husband and had 5 children.Of them her second son accidentally fell and expired at his work place 5 years ago,she felt low due to her son's demise and remained apparently asymptomatic 4 years ago, after the demise of her husband (due to renal issues - due to breathlessness; he was chronic smoker and alcoholic); she was feeling low and continued to look after her grandchildren at home, and does household works. She started taking pain killers twice daily and sometimes injections since 2 years due to body pains. On 2nd may, after the demise of her grandson; she constantly feeling low and not taking food properly, took only small quantity of fluids (milk and water). Her relatives noticed swelling of both lower limbs till ankle. Since 20 days she had complaints of Breathlessness while walking and unable to perform her routine activities which has progressed to breathlessness at rest since last 6 to 7 days. Decrease in urinary output since 10 days. She had complaints of fever since 5 days, associated with chills and rigors.

PAST HISTORY:
Hypertensive on unknown medication since 6 months.
She had h/o neckpain and headache 6months ago,on getting checked by local RMP she was found to have high blood pressure
PERSONAL HISTORY:
Appetite decreased.
Bowel movements regular.
Decreased urinary output.
Daily routine:
Wakes up at around 5:30attends nature calls and cooks for the family,around 10 am goes to gricultural or household work an returns home around 4pm,consumes rice 3 times daily for breakfast lunch and dinner and sleeps around 9:30 to 10 pm,after demise of her grand so she has diatribes and decreased sleep time.

No known allergic history.

Addictions:
No

Family history:
No similar complaints in the family.

Menstrual history:
Attained menopause 15 years ago.

Vitals at presentation:
Temp: 99.1 F
PR : 110 bpm
BP : 140/80 mmHg
SpO2 : 99% @ RA
GRBS : 216 mg/dl.

Course in hospital:
A 64 year female was brought to casuality with above mentioned complaints, upon arrival to ER, on examination patient had bilateral lower lobe crepts and diffuse wheeze in bilateral lung fields. Her room air stats were 99%, she was managed by medicine resident on duty by nebulization with salbutamol and abg was taken at room air.
pH: 7.009
pCo2: 14.7
pO2: 60.6
HCO3-: 3.5
SaO2: 82.1
FiO2: 21%
s/o partially compensated metabolic acidosis.
300 meq of sodium bicarbonate correction was given as slowly via IV in the ER. Meanwhile necessary investigations were sent. 
ECG:



Chest x ray :


After shifting patient to ICU, a screening usg abdomen was done which showed raised echogenicity of bilateral kidneys. Patient was transferred to nephrology i/v/o raised urea and creatinine. Patient was in altered state at time of cross consultation by nephrologist. A Right femoral vein double lumen catherization was done and patient was taken up for hemodialysis. Before shifting patient to hemodialysis, he had an episode of GTCS, lasted for around 2 minutes, and stat dose of antiepileptic agent was given. patient was initiated on dialysis. Patient underwent intadialysis PRBC transfusion during 1st and 2nd HD session. 

2D echo:


INVESTIGATIONS CHART:


Provisional diagnosis:
1. Altered sensorium 2° to uremic encephalopathy.
2. GTCS 2° to Uremia.
3.Chronic Renal Failure
4. Hypertension • 6 months
5.Denovo Diabetes 
6.Grade 2 bed sore

Management:
1. Ryles tube feeding.
2. INJ. PIPTAZ 2.25 gr/IV/TID 
3. INJ. LASIX 40 mg/IV/BD
4. TAB. SHELCAL 500 Mg/RT/OD
5. TAB. OROFER XT po/OD
6. INJ. HUMAN ACTRAPID INSULIN /SC/TID ACC. TO GRBS.
7.TAB.CINOD 10mg po/od

Factors influencing outcomes in this case:-
-Unhealthy lifestyle and eating habits(consumes more carbohydrates)
-Effected mental health due to family members demise
-Overweight
-Delayed diagnosis of hypertension
-poor socioeconomic status
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