A CASE OF 70 YEAR OLD MALE WITH CRF

92 Sneha Nadipi

3rd Semester

Under the guidance of Dr.Roshini Reddy(intern) and Dr.Vaishnavi(PG)

This is 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 patients clinical problems with collective current best evidence based inputs.

🖌This is an ongoing case. This blog post will be updated regularly.

   

*️⃣CASE SENERIO:

🌡CHIEF COMPLAINTS:

📌Epigastric pain since 4 days

📌SOB since 4 days

🌡HISTORY OF PRESENT ILLNESS

Patient was apparently a symptomatic four days back then he developed 

Epigastric pain and SOB since 4 days.

📌Lower limb swelling since 4 days

📌 C/O Fever, C/O cough with sputum since 4 days

📌 C/O Burning micturation 

📌 C/O decreased urine output since four days

📌C/O Constipation since four days

No h/o palpitations 

No h/o of chest pain 

No diurnal variation 

🌡PAST HISTORY 

📌k/c/o CKD And patient is on conservative treatment for the same.

📌K/c/o HTN (since 6months) and is on irregular medication for same.

📌Not a known case of DM/TB/Asthma/Epilepsy/CAD/CVA/Thyroid disorders.

🌡 TREATMENT HISTORY :

📌Irregular medication for HTN since  one year

📌The patient was diagnosed with CKD four years ago and is on  irregular treatment since then.

📌The patients was given medication for TB 20 years ago(no clear history)

🌡PERSONAL HISTORY : 

-  Married 

-Non-vegetarian

- Apettite loss:Yes

- Bowels : Constipation

- Micturition : Decresed Urine output and burning micturition

- No H/O known drug allergies

Addictions:

-Alcohol : regular (stopped 3 years ago)

Smoking:Chronic chutta  smoker 4-5 per day (stopped 4 years ago)

🌡FAMILY HISTORY 

📌Insignificant

🌡PHYSICAL EXAMINATION : 

A) GENERAL EXAMINATION :

Patient is consious,coherent and cooperative,moderately built and moderately nourished 

 Pallor- YES 

lcterus-NO

Cyanosis-No. 

 Clubbing of fingers/toes- No

Lymphadenopathy-No

Oedema of  feet- YES

Malnutrition - Moderately nourished 

Built-Moderately built 

Dehydration -NO 

No H/O, cyanosis , lymphadenopathy , clubbing of fingers or toes , dehydration

🌡SYSTEMIC EXAMINATION:

B) CVS 

- Thrills : No 

- Cardiac sounds - S1 , S2 heard 

- Cardiac murmurs : No 

C) RS 

- BAE-PRESENT

- Dyspnea : NO

- Wheeze :Expiratory wheeze present

-Inspiratory crepts-B/L IAA ,ISA

D) ABDOMEN 

- Distended

E)CNS:-Normal

1. Higher Mental Function:-

• Alert and conscious 
• Normal speech

2. Cranial nerves -

•  all cranial nerves 

                               - gag reflex
                               -  vulva position

3. Motor system - attitude -

                                       Rt.              Lt.  

        •Reflexes. B         +                 +

                          T          +                 +

                          S          +                 +

                          K          +                 +

                          A          +                 +

                     Plantars-flexors

🌡SEROLOGICAL INVESTIGATIONS:

Hb-9.8 g/dl

TLC-5170 cumm

PLT(plateletcount)-43,000 cumm

Serum creatinine: 9 mg/ dl

Blood urea: 126 mg/dl

16/8/21

Serum Iron

, '

LFT

.

17/8/21:

Blood urea: 238 mg/ dl

Calcium:9.9 mg/dl

Sodium : 129mEq/L

potassium : 3.5 mEq/L

chloride : 93 mEq/l

ABG

pH:7.20

Co2–24.6 mmHg

HCO3 -11.6 mEq/mol

Liver Function Test:

TB   -1.08 mg/dl

DB   -0.18 mg/dl

AST -31 IU/lit

ALT  -88 IU/lit

Alkaline Phosphate-345 IU/lit

TP:6.2 g/dl

Alb-3.5 g/dl

A/G-1.30 g/dl

BLOOD UREA 

Serum Creatinine

18/4/21

Electrolytes:

Na-124 mmol/lit

K-3.6 mmol/lit

Cl-86 mmol/lit

Hb-10.8 g/dl

TLC-4990 /cumm

PLT-50,000 /cumm

PT-16 seconds

INR-1.11 

Blood Urea-145 mg/dl

Creatinine-6.7 mg/dl

Uric Acid-7.9 mg/dl

Calcium-7 mg/dl

ECG

Hemogram

ABG

RFT

       At 10:27 AM

At 11:44 PM

Bacterial culture and sensitivity report 

CBP

APTT

Prothrombin Time

19/8/21

Urea -167 mg/dl

Creatinine-5.8 mg/dl

Calcium-7 mg/dl

Phosphate-2.2 mg/dl

Electrolytes:

Na-126 mmol/lit

K-2.9 mmol/lit

Cl-88 mmol/lit

Hb-10.5 g/dl

TLC-6,200 /cumm

PLT-40,000 /cumm

ABG

RFT

PROVISIONAL DIAGNOSIS: 

CRF

?VIRAL THROMBOCYTOPENIA 

?COPD

K/C/O HTN

Treatment

16/08/21

1. Inj Lasix 40mg/IV/TID (If SBP ≥ 110 mm of hg)

2. T Nodosin 500mg/PO/TID

3. T Shelcal 500mg/PO/OD

4. T Oeofer-XT/PO/BD

5. T Amlong 5mg/PO/OD

6. Monitor vitals 4th hourly

7. Strict I/O charting

8. GRBS 8th hourly

9. Neb Duolin - 8th hourly

             Budecort - 12th hourly

17/08/21

1. Inj Lasix 40mg/IV/BD

2. Tab NODOSIS 500mg/PO/TID

3. Tab Shelcal 500mg/PO/OD

4. Tab orofex-XT 

5. Tab Amlung 5mg/PO/BDL

18/08/21

1. T NORDOSIS 500mg/PO/TID

2. T Shelcal 500mg/PO/OD

3. T Orofer - XT 

4. T Amlong 5mg/PO/OD

19/08/21

Inj LASIX 40mg IV

Inj PAN 40mg IV

Inj CEPRAXONE 1gm IV

Tab NODOSIS 500mg P/O TID

Tab OROPER-XT P/O BD

Tab AMLONG 500mg P/O OD

Tab SHELCAL 500mg P/O OD

NEB -IPRANENT-8th hrly

        -BUDUCART-12th hrly

FLUID LESLNELM <1.5 or 1 per day

Discharge Summary 

🌡CHIEF COMPLAINTS:

📌Epigastric pain since 4 days

📌Lower limb swelling since 4 days

📌SOB since 4 days

📌Fever cough with sputum since 4 days

📌Burning micturation and decreased urine output since four days

📌Constipation since four days

🌡HISTORY OF PRESENT ILLNESS

Patient was apparently a symptomatic four days back then he developed 

Epigastric pain and SOB since 4 days.

📌Lower limb swelling since 4 days

📌 C/O Fever, C/O cough with sputum since 4 days

📌 C/O Burning micturation 

📌 C/O decreased urine output since four days

📌C/O Constipation since four days

No h/o palpitations 

No h/o of chest pain 

No diurnal variation 

🌡PAST HISTORY 

📌k/c/o CKD And patient is on conservative treatment for the same.

📌K/c/o HTN (since 6months) and is on irregular medication for same.

📌Not a known case of DM/TB/Asthma/Epilepsy/CAD/CVA/Thyroid disorders.

🌡 TREATMENT HISTORY :

📌Irregular medication for HTN since  one year

📌The patient was diagnosed with CKD four years ago and is on  irregular treatment since then.

📌The patients was given medication for TB 20 years ago(no clear history)

🌡PERSONAL HISTORY : 

-  Married 

-Non-vegetarian

- Apettite loss:Yes

- Bowels : Constipation

- Micturition : Decresed Urine output and burning micturition

- No H/O known drug allergies

Addictions:

-Alcohol : regular (stopped 3 years ago)

Smoking:Chronic chutta  smoker 4-5 per day (stopped 4 years ago)

🌡FAMILY HISTORY 

📌Insignificant

🌡PHYSICAL EXAMINATION : 

A) GENERAL EXAMINATION :

Patients is k/c/o Moderately built and Malnourished 

 Pallor- YES

lcterus-NO

Cyanosis-No.  

Clubbing of fingers/toes- No

Lymphadenopathy-No

Oedema of  feet- YES

Malnutrition - Moderately nourished 

Built-Moderately built 

Dehydration -NO 

No H/O, cyanosis , lymphadenopathy , clubbing of fingers or toes , dehydration

🌡SYSTEMIC EXAMINATION:

B) CVS 

- Thrills : No 

- Cardiac sounds - S1 , S2 heard 

- Cardiac murmurs : No 

C) RS 

- BAE-PRESENT

- Dyspnea : NO

- Wheeze :Expiratory wheeze present

-Inspiratory crepts-B/L IAA ,ISA

D) ABDOMEN 

- Distended

E)CNS:-Normal

1. Higher Mental Function:-

• Alert and conscious 
• Normal speech

2. Cranial nerves -

•  all cranial nerves 

                               - gag reflex
                               -  vulva position

3. Motor system - attitude -

                                       Rt.              Lt.  

        •Reflexes. B         +                 +

                          T          +                 +

                          S          +                 +

                          K          +                 +

                          A          +                 +

                     Plantars-flexors

PROVISIONAL DIAGNOSIS: 

CRF

?VIRAL THROMBOCYTOPENIA 

?COPD

K/C/O HTN

SOAP NOTES

Day -1

16/8/21 

Subjective

       C/O

        Epigastric pain

        Lower limb swelling

        SOB 

        Fever cough with sputum 

        Burning micturation and decreased urine output   

        Constipation

        

        

Objective:

Temperature 

8 pm - 98.61 

10 pm- 97.61

12 am - 98.61 

2 am - 97.61

 4 pm - 98.61 

6 am - 97.62

 pulse rate

8 pm - 85:

10 pm - 84 

12 am - 89 

4am - 84 

6 am - 84

RR 

8 pm - 20 

10pm - 20 

12 am - 18 

2 am - 20

4 am - 18 

6 am - 20

Spo2 (%) 

8 pm - 98 

10 pm - 97 

12 am - 98 

2 am - 97 

4 am - 98 

6 am - 98

BP 

8 pm - 130/70

12 am - 130/70 

2 am - 110/80 

4 am - 110/80

 6 am - 120/80

Assessment :-

Epigastric pain

SOB

Thrombocytopenia 

Plan of care:-

1. Inj Lasix 40mg/IV/TID (If SBP ≥ 110 mm of hg)

2. T Nodosin 500mg/PO/TID

3. T Shelcal 500mg/PO/OD

4. T Oeofer-XT/PO/BD

5. T Amlong 5mg/PO/OD

6. Monitor vitals 4th hourly

7. Strict I/O charting

8. GRBS 8th hourly

9. Neb Duolin - 8th hourly

             Budecort - 12th hourly

Day -2

17/08/21

Subjective

C/O

        Epigastric pain

        Lower limb swelling

        SOB 

        Fever cough with sputum 

        Burning micturation and decreased urine output   

        Constipation 

         

      

Objective:-

Tempature ( °F) 

8 am - 98.61 

10 am - 98.6 

12 pm - 98.6 

2 pm - 99.6 

4 pm - 99.6 

6pm - 99.6 

8 pm - 98.6

Pulse rate 

8 pm - 84 

10 am - 88

12 pm - 84 

2pm - 84 

4 pm - 88

6 pm - 84 

8 pm - 82

RR 

8 am - 20 

10 am - 18

12 pm - 18 

2 pm - 20

4 pm - 20 

6 pm - 21 

8 pm - 19

Spo2 (%) 

8am - 98 

10 am - 92 

12 pm - 92 

2 pm - 93 

4 pm - 92 

6 pm - 93 

8 pm - 94

BP 

8 am - 120/80 

10 am - 110/70 

12 pm - 110/70 

2pm - 110/80 

4 pm - 130/70 

 6 pm - 120/80

 8 pm - 120/70

Assessment :

Epigastric pain

SOB

Chronic Renal Failure 

Known case of hypertension 

COPD

Plan of care:-

1. Inj Lasix 40mg/IV/BD

2. Tab NODOSIS 500mg/PO/TID

3. Tab Shelcal 500mg/PO/OD

4. Tab orofex-XT 

5. Tab Amlung 5mg/PO/BDL

Day -3

18/08/21

Subjective-

C/O

       

        Lower limb swelling

        Fever cough with sputum 

        Burning micturation and decreased urine output   

        Constipation 

        Decreased Epigastric pain

          Decreased SOB

Objective:- 

BP:120/70 mmHg

PR-142 bpm-regular 

Spo2 -98%  at room temperature 

RR-35 cpm

Assessment :-

Decreased Epigastric pain

Decreased SOB

Chronic Renal Failure 

Viral thrombocytopenia (current PLT-1 lakh cumm)

COPD

Known case of HTN

Plan of care:-

1. T NORDOSIS 500mg/PO/TID

2. T Shelcal 500mg/PO/OD

3. T Orofer - XT 

4. T Amlong 5mg/PO/OD

Day -4

19/08/21

Subjective-

C/O

        Decreased Epigastric pain

        Lower limb swelling

        Fever cough with sputum 

        Burning micturation and decreased urine output   

        Constipation 

         Decreased SOB 

Objective:-

Temperature °F 

1 am - 98.6 

2am - 98.6 

4 am - 98.7 

6 am - 98.6 

8 am - 98.6

Pulse rate 

1 am - 82 

2 am - 86 

4 am - 84 

6 am -86 

8 am - 82

RR 

1am - 19 

2 am - 22 

4 am - 26 

6 am - 26 

8 am - 24

Spo2 

1 am - 96 

2 am - 98

4 am - 98

6 am - 98

8 am - 99

BP 

 1 am - 120/80 

2 am - 120/80 

4 am - 120/80 

 6 am - 120/80 

8 am - 120/80

Assessment :

Decreased Epigastric pain

Decreased SOB

CRF

Viral thrombocytopenia 

COPD

Known case of HTN 

Past h/o of pulmonary Koch

Hyponatremia (hypervolemia 2 to CRF)

Hypocalcemia

Plan of care:-

Inj LASIX 40mg IV

Inj PAN 40mg IV

Inj CEPRAXONE 1gm IV

Tab NODOSIS 500mg P/O TID

Tab OROPER-XT P/O BD

Tab AMLONG 500mg P/O OD

Tab SHELCAL 500mg P/O OD

NEB -IPRANENT-8th hrly

        -BUDUCART-12th hrly

FLUID LESLNELM <1.5 or 1 per day

FEVER CHART(16/08-19/08)

Treatment

16/08/21

1. Inj Lasix 40mg/IV/TID (If SBP ≥ 110 mm of hg)

2. T Nodosin 500mg/PO/TID

3. T Shelcal 500mg/PO/OD

4. T Oeofer-XT/PO/BD

5. T Amlong 5mg/PO/OD

6. Monitor vitals 4th hourly

7. Strict I/O charting

8. GRBS 8th hourly

9. Neb Duolin - 8th hourly

             Budecort - 12th hourly

17/08/21

1. Inj Lasix 40mg/IV/BD

2. Tab NODOSIS 500mg/PO/TID

3. Tab Shelcal 500mg/PO/OD

4. Tab orofex-XT 

5. Tab Amlung 5mg/PO/BDL

18/08/21

1. T NORDOSIS 500mg/PO/TID

2. T Shelcal 500mg/PO/OD

3. T Orofer - XT 

4. T Amlong 5mg/PO/OD

19/08/21

Inj LASIX 40mg IV

Inj PAN 40mg IV

Inj CEPRAXONE 1gm IV

Tab NODOSIS 500mg P/O TID

Tab OROPER-XT P/O BD

Tab AMLONG 500mg P/O OD

Tab SHELCAL 500mg P/O OD

NEB -IPRANENT-8th hrly

        -BUDUCART-12th hrly

FLUID LESLNELM <1.5 or 1 per day