50 Y OLD MALE WITH HYPERKALEMIA SECONDARY TO AKI

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I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

Following is The view of My case 

Date of Admission :- 5-6 months 

Cheif complaints 

C/o swelling of Lower and upper limbs - since 5-6 months 

HOPI 

Patient was apparently asymptomatic 5-6 months back.Then he developed Swelling of body - Facial Puffiness, swelling of handsand legs - Insidious in onset , gradually progressive - On and Off 

Swelling of both lower limbs - Pitting , extending upto knee, Relieved upon lying down, aggrevated on Sitting/walking.

Patient also complaints of decreased Urine Output since 10 days associated with burning micturition. 

Patient also complains of low grade fever associated with Chills and rigors.

H/O Grade 2 SOB since 10 days releived on Rest.

No H/O  pain abdomen/Abdominal distension/chest pain/ Palpitations/orthopnea/PND 

Comorbidities:- 

K/c/O DM 2 on T. METFORMIN 500MG BD

K/C/O HYPERTENSION on T.AMLODIPINE 10 MG OD

K/C/O EPILEPSY OM MEDICATION SINCE 2 YEARS ON T. LEVIPIL 750MG OD

K/C/O CAD ON MEDICATION SINCE 2 YRS ON T. CLOPIDOGREL OD 

Not a K/C/O TB, CVA, Asthma,  thyroid disorder 

PERSONAL HISTORY:

Diet mixed

Sleep normal

Regular bowel and bladder habits

Alcoholic, stopped 2 years back.

Smoker, stopped 2 years back

No significant family History

GENERAL EXAMINATION:

O/E 

Patient is conscious coherent cooperative

Afebrile on touch

PR : 84bpm

RR : 16cpm

BP : 140/80 mm of hg

Grbs :119 mg/dl

SYSTEMIC EXAMINATION:

RS: BAE , NVBS no added sounds

CVS : S1 S2 heard no murmurs

P/A : soft , non tender

CNS : higher mental functions intact

Tone normal in all 4 limbs

Power 5/5 in all limbs

All reflexes present.

Ophthalmology referral was done for diabetic retinopathy 

They have done fundoscopy and reported that the patient had findings s/o bilateral non proliferative diabetic retinopathy 

OFMS Referral was done i/v/O toothache 

INVESTIGATIONS:

Hb- 8.9gm/dl

TLC- 5200cells/cu.mm

PLT- 3.43 lakhs/cu.mm

CUE:

Albumin: present(3+)

Pus cells: 3-4

Epithelial cells: 2-3

RBS: 131mg/dl

Na- 140mEq/L

K- 6mEq/L

Cl-108mEq/L

Ca- 1.20mmol/L

Serum creatinine- 1.7mg/dl

Blood urea- 69mg/d

Chest x ray 

28/2/2023

2/3/23

USG ABDOMEN:

1. GB wall edema

2. Minimal ascites

3. B/L pleural effusion-S/o polyserositis

4. Grade I RPD changes in B/L kidneys

5. Mild bladder wall thickening? Cystitis.

ECG:

2D echo 

22/2/2023

23/2/2023

24/2/2023

25/2/2023

26/2/23

27/2/2023

28/3/23

1/3/2023

2/3/23

3/3/23

4/3/23

5/3/23

6/3/23

7/3/23

9/3/23

PROVISIONAL DIAGNOSIS:

HYPERKALEMIA SECONDARY TO ?ACUTE RENAL FAILURE.

FEVER UNDER EVALUATION 

K/C/O DM2, HTN, CAD.

TREATMENT:

1. INJ HAI S/C premeal /TID

2.Tab. NICARDIA 10mg PO/OD

3.Tab. ECOSPIRIN- AV(75/10) PO/HS

4. Nebulisation with SALBUTAMOL 2 RESPULES EVERY 4th HOURLY

5. Tab. LASIX 40mg PO BD

SOAP NOTES

28/2/2023
50 year old male came with the c/o swelling of lower and upper limbs since 5-6 months
S
SOB subsided
Tooth pain reduced
O
Pt is c/c/c
Temp- 98.3 F
PR- 82bpm
BP- 140/90mmhg
RR- 18cpm
GRBS- 82mg/dl
Spo2- 98% @ RA
I/O :- 1300ml/650ml
CVS- S1S2 heard, no murmurs
RS- B/L air entry (+)
Crepts + in left Infra axillary area
Normal vesicular breath sounds In All other areas
P/A- Soft, non tender
CNS- NFND
A
HEART FAILURE WITH MIDRANGE EJECTION FRACTION (EF=50%) WITH RENAL AKI ON CKD SECONDARY TO DIABETIC NEPHROPATHY WITH DIABETIC RETINOPATHY
P
Fluid restriction <1.5lit/day
Salt restriction <2gm/day
Inj HAI S/C  TID
Inj Lasix 40mg IV BD
Tab Nicardia 10mg PO TID
Tab PCM 650mg PO SOS
Tab Shelcal 500mg PO OD
Neb with Salbutamol 2 repsules every 4th hourly




1/3/2023


Admission date: 22/02/2023
AMC BED 3
50 year old male came with the c/o swelling of lower and upper limbs since 5-6 months
S
SOB subsided
Tooth pain reduced
O
Pt is c/c/c
Temp- 98.5F
PR- 86bpm
BP- 140/90mmhg
RR- 20cpm
GRBS- 74mg/dl
Spo2- 99% @ RA
CVS- S1S2 heard, no murmurs
RS- B/L air entry (+)
Bilateral Basal Crepts+
Normal vesicular breath sounds In All other areas
P/A- Soft, non tender
CNS- NFND
A
HEART FAILURE WITH MIDRANGE EJECTION FRACTION (EF=50%) WITH RENAL AKI ON CKD SECONDARY TO DIABETIC NEPHROPATHY WITH DIABETIC RETINOPATHY
P
Fluid restriction <1.5lit/day
Salt restriction <2gm/day
Inj HAI S/C  TID
Inj Lasix 40mg IV BD
Tab Nicardia 10mg PO
TID
Tab PCM 650mg PO SOS
Tab Shelcal 500mg PO OD
Neb with Salbutamol 2 repsules every 4th hourly


Plan for Dialysis Today after Consulting Nephrologist





2/3/23


S
SOB subsided
Tooth pain reduced
O
Pt is c/c/c
Temp- 98.5F
PR- 86bpm
BP- 170/100mmhg
RR- 26cpm
GRBS- 103mg/dl
Spo2- 96% @ RA                        I/O 800/700mL
CVS- S1S2 heard, no murmurs
RS- B/L air entry (+)
Bilateral Basal Crepts+
Normal vesicular breath sounds In All other areas
P/A- Soft, non tender
CNS- NFND
A
HEART FAILURE WITH MIDRANGE EJECTION FRACTION (EF=50%) WITH RENAL AKI ON CKD SECONDARY TO DIABETIC NEPHROPATHY WITH DIABETIC RETINOPATHY
P
Fluid restriction <1.5lit/day
Salt restriction <2gm/day
Inj HAI S/C  TID
Inj Lasix 40mg IV BD
Tab Nicardia 10mg PO
TID
Tab PCM 650mg PO SOS      Tab. ULTRACET PO/BD
Tab Shelcal 500mg PO OD
Neb with Salbutamol 2 repsules every 4th hourly


3/3/23

50 year old male came with the c/o swelling of lower and upper limbs since 5-6 months
S
SOB subsided
Tooth pain reduced
O
Pt is c/c/c
Temp- 98.5F
PR- 86bpm
BP- 170/90mmhg
RR- 18cpm
GRBS- 104mg/dl
Spo2- 96% @ RA                    
   I/O 700/600mL
CVS- S1S2 heard, no murmurs
RS- B/L air entry (+)
Bilateral Basal Crepts+
Normal vesicular breath sounds In All other areas
P/A- Soft, non tender
CNS- NFND
A
HEART FAILURE WITH MIDRANGE EJECTION FRACTION (EF=50%) WITH RENAL AKI ON CKD SECONDARY TO DIABETIC NEPHROPATHY WITH MILD NON PROLIFERATIVE  DIABETIC RETINOPATHY
K/C/O HTN SINCE 5 YRS, CAD 2YRS AGO ANS DM2 SINCE 10 YRS
P
Fluid restriction <1.5lit/day
Salt restriction <2gm/day
Inj HAI S/C  TID
Inj Lasix 40mg IV BD
Tab Nicardia 10mg PO
QID
Tab PCM 650mg PO SOS

6/3/23

50 year old male came with the c/o swelling of lower and upper limbs since 5-6 months
S
SOB subsided
Tooth pain reduced
O
Pt is c/c/c
Temp- 98.5F
PR- 86bpm
BP- 170/90mmhg
RR- 18cpm
GRBS- 104mg/dl
Spo2- 96% @ RA                    
   I/O 700/600mL
CVS- S1S2 heard, no murmurs
RS- B/L air entry (+)
Bilateral Basal Crepts+
Normal vesicular breath sounds In All other areas
P/A- Soft, non tender
CNS- NFND
A
HEART FAILURE WITH MIDRANGE EJECTION FRACTION (EF=50%) WITH RENAL AKI ON CKD SECONDARY TO DIABETIC NEPHROPATHY WITH MILD NON PROLIFERATIVE  DIABETIC RETINOPATHY
K/C/O HTN SINCE 5 YRS, CAD 2YRS AGO ANS DM2 SINCE 10 YRS
P
Fluid restriction <1.5lit/day
Salt restriction <2gm/day
Inj HAI S/C  TID
Inj Lasix 40mg IV BD
Inj.Erythropoietin 4000U s/c  once weekly
Tab Nicardia 10mg PO
QID

Case transferred to nephrology in view of Ckd ans presently the patient is undrrgoing hemodialysis