General medicine case-2

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here, we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

Date of admission: 11th August 2021

A 60 year old male presented to the OPD with chief complaints of pain in the lower back, burning sensation during urination since 15 days.

History of present illness:

Patient was apparently asymptomatic 1 week back then he had insidious onset of fever , low grade and intermittent not associated with chills and rigors. He complains of lower back pain and swelling in the limbs.

The patient's wife used home remedies to treat swellings in the limb.

Since 1 month, the patient again developed pedal edema and facial puffiness.

The patient has been undergoing dialysis since 13 days for every 2 days.

Past history:

He is a known case of hypertension since 2 years.

Not a known case of CAD, Asthma,TB, Epilepsy, Thyroid disorders.

No history of sugeries.

Personal history: 

The patient has a mixed diet.

Appetite is normal.

The patient has constipation, decreased urine output with burning micturition.

He is a known case of beedi smoker since many years.

Known case of alcoholic.

Family history:

There is no history of DM, hypertension, CAD, CVA or similar complaints in the family.

Treatment history:

No history of drug allergies.

General examination : 

- On examination the patient is conscious, coherent, cooperative

- Pallor is present

- No cyanosis

- No icterus 

- No clubbing of fingers or toes

- No lymphadenopathy

- Bilateral pedal edema present.

Vitals : temperature - 99.4⁰F

              Pulse rate - 103/min

              Respiratory rate - 28 cycles per minute

              Spo2 - 95%

              BP - 130/70 mm Hg


Systemic examination: 

CVS:

Inspection: chest is barrel shaped 

No visible pulsations, engorged veins, scars, sinuses

Palpation - JVP is normal

Auscultation - S1 and S2 heard

RESPIRATORY SYSTEM

- Position of trachea is central

- Bilateral air entry us normal

- Normal vesicular breath sounds heard

- No added sounds


PER ABDOMEN :

abdomen is not tender

- bowel sounds heard

- no palpable mass or free fluid.


CNS:

- Patient is conscious

- Speech is present

- Reflexes are normal.

Provisional diagnosis: urinary tract infection, kidney failure.

Investigations: 










Hemogram : 

On 12/08/21:

Hemoglobin : 7.7 gm/dl

Total count : 11000 cells/cumm

Neutrophils : 80%

Lymphocytes : 9%

Eosinophils : 1%

Monocytes : 10%

Basophils : 0%

Platelet count : 1.56 lakh /cumm

Smear : normocytic normochromic anemia

On 13/08/21:

Hemoglobin : 5.2 gm/dl

Total count : 92000 cells/cumm

Neutrophils : 87%

Lymphocytes : 5%

Eosinophils : 2%

Monocytes : 6%

Basophils : 0%

Platelet count : 1.5 lakh /cumm

Smear : normocytic normochromic anemia with relative neutrophilia.

On 14/08/21:

Hemoglobin : 6.9 gm/dl

Total count : 13100 cells/cumm

Neutrophils : 87%

Lymphocytes : 4%

Eosinophils : 1%

Monocytes : 8%

Basophils : 0%

Platelet count : 1.57 lakh /cumm

Smear : normocytic normochromic anemia with neutrophilic leucocytosis.

On 15/08/21:

Hemoglobin : 7.1 gm/dl

Total count : 13400 cells/cumm

Neutrophils : 64%

Lymphocytes : 7%

Eosinophils : 2%

Monocytes : 7%

Basophils : 0%

Platelet count : 2.38 lakh /cumm

Smear : normocytic normochromic anemia with neutrophilic leukocytosis abd thrombocytopenia blood picture.

On 18/08/21:

Hemoglobin : 8 gm/dl

Total count : 10100 cells/cumm

Neutrophils : 80%

Lymphocytes : 10%

Eosinophils : 3%

Monocytes : 7%

Basophils : 0%

Platelet count : 2.10 lakh /cumm

Smear : normocytic normochromic blood picture.

On 22/08/21:

Hemoglobin : 9.7 gm/dl

Total count : 8100 cells/cumm

Neutrophils : 65%

Lymphocytes : 23%

Eosinophils : 4%

Monocytes : 8%

Basophils : 0%

Platelet count : 3.68 lakh /cumm

Smear : normocytic normochromic anemia.


Final diagnosis:

Acute renal failure.

Treatment:

1. HIGH FLOW OXYGEN

2. IVF - 20NS @ 75ml/hr

3.  RT feeds - 200ml Milk and protein powder.

2nd hourly

100ml plain water 2nd hourly

4.Inj. PIPTAZ 2.25 gm/IV/TID

5. Inj. METROGYL 100ml/IV/TID

6. Inj. PANTOP 40 mg/IV / OD

7. TAB. LASIX 40 mg/ RT/ SOS if SBP ≥110 mm/hg

8. TAB. NODOSIS 500 mg/ RT/ BO

9. TAB. DOLO 650 mg/ RT /BD

10. NEBULIZATION with DUOLIN /IN/ TID

                                              BUDECORT/IN/BD

11. Syp. LACTULOSE 10ml/RT/HS

12. PR/BP/RR/SPO2 charting 2nd hourly

13. I/O charting.

Is there any other disease involving lower back pain and kidney failure?

Does asthma have a role in causing  renal failure?

What are the effects of long-term cigarette smoking on kidney failure?

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