62Y Male with PEDAL EDEMA since 6 Months & DECREASED URINE OUTPUT since 1 Month

Introduction: This is an online E-log Entry Blog to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs. 

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.

Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references. 

A 62-year-old male, saree weaver by occupation presented with the,

CHIEF COMPLAINTS:

1. Pedal Edema since 6-7 months.

2. Decreased urine output since 1 month.

3. Vomiting since 10-12 days. 

4. Shortness of breath and facial puffiness since 2 days. 

HISTORY OF PRESENTING ILLNESS:

 Patient was apparently asymptomatic 8-9 months back, when he started developing hypoglycemic episodes (sugar levels used to drop to around 30 mg/dl) 2-3 times a week and during the episode patient behaved violently and had altered sensorium according to attenders.

↓

Visited local practitioner and patient was given 25 Dextrose and sugar levels improved.

 

↓

7 months back he developed pedal edema and due to repeated episodes of hypoglycemia, patient attenders took him to hospital, where upon investigating, they were informed that kidney function tests were abnormal.

- Creatinine 5.4 mg/dl , Urea 123mg/dl.

- Albumin +++

- Diagnosed with Renal Failure and treated conservatively.

↓

Since last 1 month C/O Decreased urine output

↓

C/O vomitings since 10-12 days - non projectile, non-bilious, food particles as content, non-blood tinged. 

↓

C/O shortness of breath since 2 days, grade II, relieved on taking rest.

↓

C/O facial puffiness since 2 days.

EVENTS:

15 years back, Patient developed fever with chills and joint pains - Diagnosed as Chikungunya 

- On getting routine investigations done, patient was diagnosed with Diabetes Mellitus Type 2 and started on Oral hypoglycemic agents.

↓

8 Years back, his sugar levels when checked at home were 936 mg/dl (according to his son) and his local practitioner recommended to switch to insulin medication once a week from his previous OHG drugs.

↓

During the third week, due to improper storage condition of insulin at the local pharmacy, after injecting it, patient felt discomfort and visited hospital where they were told about insulin poisoning.

↓

Patient was then started on MIXTARD injection and since then had no complaints.

↓

3-4 years back, he developed cough which increased in the night, not associated with fever, chills or vomitings and was admitted for 22 days in the hospital.

- Diagnosed with Pulmonary Tuberculosis (after identifying a cavity in lung on CT thorax, Sputum for CBNAAT was negative) and used ATT for 6 months. 

 ↓

During his hospital stay, his sugar levels were constantly fluctuating, hence his insulin medication was once again changed to HUMULIN N and R. 

↓

The patient was then symptom free till 8-9 months back.

PAST HISTORY:

• Patient is a known case of Diabetes Mellitus type 2, since 15 years, on Inj Mixtard. 
• Patient is a known case of Hypertension since 3 years on Tab AMLONG 10mg. 
• Patient is a known case of Tuberculosis 3-4 years back.
• Patient is a known case of CKD since 6 months.
• Patient is not a known case of Thyroid disorders, Seizures, Asthma, stroke or any cardiac disorder.

PERSONAL HISTORY:

• His appetite has decreased since past 10 days, he consumes a mixed diet. 
• Bowel movements decreased since 3 days (constipation).
• Decreased urine output since 1 month. 
• No history of smoking.
• Occasional alcohol consumption but stopped 4-5 years back.
• No known food or drug allergies.

FAMILY HISTORY:

• No similar complaints in the family members.

GENERAL PHYSICAL EXAMINATION:

On admission: 

Patient is conscious, coherent and cooperative, well oriented to time, place and person. 

Pallor present 

No signs of cyanosis, icterus, lymphadenopathy, clubbing

Bilateral pedal Edema+

JVP normal

On 13/07/2023 

Patient is drowsy, not obeying commands, not oriented to time, place or person. 

Pallor present 

No signs of cyanosis, icterus, lymphadenopathy, clubbing

SYSTEMIC EXAMINATION:

Per Abdomen: Soft and nontender

Cardiovascular System: S1, S2 heard, no murmurs 

Respiratory System: BAE+, NVBS +

Central Nervous System Examination:

11/07/2023; 12/07/2023:  NFAD

13/07/2023:  GCS: E4V2M4 (10/15)

Tone                Right            Left

         UL            ↑                   ↑

         LL            ↑                   ↑

Power

         UL           3/5               4/5

         LL           3/5               4/5

Reflexes

             Biceps      Triceps     Supinator         Knee     Ankle     Plantar

Right     ++                 ++                -                 +          -              F

Left       ++                 ++                -                 +          -              F

14/07/2023:  GCS: E4V2M6 (12/15)

Tone                Right            Left

         UL            ↑                   ↑

         LL            ↑                   ↑

Power

         UL           3/5               3/5

         LL           3/5               3/5

Reflexes

             Biceps      Triceps     Supinator     Knee     Ankle     Plantar

Right     -                  -                 -                  +          -              F

Left       -                  -                 -                  +          -              F

15/07/2023:  GCS: E4V2M6 (12/15)

Tone                Right            Left

         UL            N                  N

         LL              ↑                 ↑

Power

         UL           4/5               4/5

         LL           3/5               3/5

Reflexes

             Biceps      Triceps     Supinator     Knee     Ankle     Plantar

Right     ++                -                 +                 -            +             F

Left       ++                -                 +                 -             +           F

Vitals:

11/07/2023

Patient is conscious, coherent, cooperative.

Temperature - 98.6F

Respiratory Rate - 16 cpm

Pulse Rate - 72 bpm

Blood Pressure - 130/70 mm Hg

SpO2 - 94 @ RA

GRBS: 314mg/dl

12/07/2023

Patient is conscious. 

Temperature - 98.8F

Respiratory Rate - 22 cpm

Pulse Rate - 94 bpm

Blood Pressure - 170/80 mm Hg

SpO2 - 92 @ RA

13/07/2023

Patient is drowsy, not obeying commands.

Temperature - 101.1F (2 fever spikes+)

Respiratory Rate - 24 cpm

Pulse Rate - 101 bpm

Blood Pressure - 140/70 mm Hg

SpO2 - 98 @ 4l of o2

Urine output: 450ml ; Urine input: 600ml

14/07/2023

Patient is conscious 

Temperature - 100F (one fever spike +)

Respiratory Rate - 26 cpm

Pulse Rate - 102 bpm

Blood Pressure - 160/100 mm Hg

SpO2 - 99 @ 2l of o2

GRBS: 222mg/dl

Urine output: 1900ml ; Urine input: 1100ml

15/07/2023

Patients is conscious, coherent 

Temperature - 98.6F (no fever spike)

Respiratory Rate - 25 cpm

Pulse Rate - 99 bpm

Blood Pressure - 140/80 mm Hg

SpO2 - 99% @ 2l of o2 , 92% @RA

GRBS: 240 mg/dl

Urine output: 700ml ; Urine input: 1000ml

16/07/2023

Patients is conscious, coherent, cooperative 

GCS - 15/15

Temperature - 98.7F

Respiratory Rate - 18 cpm

Pulse Rate - 78 bpm

Blood Pressure - 130/70 mm Hg

SpO2 - 99% @RA

GRBS: 268 mg/dl

Urine output: 830ml ; Urine input: 1400ml

17/07/2023

Patients is conscious, coherent, cooperative 

GCS - 15/15

Temperature - 98.3F 

Respiratory Rate - 22 cpm

Pulse Rate - 97 bpm

Blood Pressure - 130/50 mm Hg

SpO2 - 99% @RA

GRBS: 336 mg/dl (12units HAI given) 

INVESTIGATIONS:

9th JULY 

10th JULY

11th JULY

12th JULY

13th JULY

14th JULY

1 unit PRBC Transfusion done 

15th JULY

 

C reactive protein: Negative

17th JULY

18th JULY

The patient underwent 4 sessions of Dialysis - 10/7,12/7, 14/7, 16/7.

The patient got discharged on 17/7/23 after 8 days of Hospital admission. 

PROVISIONAL DIAGNOSIS:

AKI on CKD

- Dyselectrolytemia (Hypokalemia resolving and Hyponatremia resolved)

? Dialysis Disequilibrium Syndrome (resolved)

? Metabolic Encephalopathy with Myoclonic Jerks

- with Diabetic Nephropathy

- K/C/O DM since 15 years, K/C/O Tb 3-4 years back,  K/C/O HTN since 3 years. 

TREATMENT:

1. Fluid restriction <1L/day 

2. Salt restriction <2g/day 

3. Inj HAI S/C TID , Inj NPH S/C BD (according to GRBS) 

4. RT Feeds - 2nd hourly 50ml water, 4th hourly 100ml water 

- (ryles tube removed on 17/7/23) allow soft diet and oral feeds. 

5. Inj Sodium Valproate 500mg in 100 ml NS IV/BD

- (changed to Tab Sodium Valproate 500mg PO/BD on 17/7/23) 

6. Inj EPO 4000IU IV S/C Once weekly

7. Tab AMLODIPINE 10mg PO/OD