PaJR Case Reports: 59M With Trunkal Obesity, Hypertension and CKD Telangana PaJR

06-02-2025

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

This is a case of 59 year old male who is a k/c/o hypertension since 20years and k/c/o CKD on MHD since one month presented to casualty on 04-02-2025, 3am with complaints of sudden onset severe breathlessness since 1 hour. On presentation vitals were PR 130 bpm, BP 140/90mmgh, RR 30cpm, spo2-76% @ RA, O2 supplementation and CPAP support were initiated. Complaints of respiratory distress decreased gradually, ABG and Chest X-Ray were done. ABG showed Hypoxia and met.acidosis. Chest X-Ray showed: B/L diffuse haziness. Suggestive of pulmonary edema (cardiogenic). Patient was taken up for hemodialysis with UF of 3L. Despite adequate ultrafiltration and CPAP support, respiratory distress hasn't subsided and O2 requirement increased further with hemodynamic instability. ABG sent on 05-02-25 11pm showed severe hypoxia with PO2 -30mmHg and attenders were counselled about the need for mechanical ventilation and patient was intubated with ET.NO:7 and position confirmed with mist in tube 5-point Auscultation. At around 1.30am patient developed sudden bradycardia with not recordable BP and absent central pulses. CPE was initiated accordingly.

04-02-2025

Afternoon AMC ward: 59M with trunkal obesity, Hypertension and renal stones detected 20 years back and then lost to follow up although the patient continued taking regular amlodipine and metoprolol. Presented yesterday with severe LVF and azotemia. @PA this is perhaps similar to what may emerge in the current patient of renal stones and azotemia that you have logged.

PPM 1 - 👆Post admission pharmacological and non pharmacological interventions and BP outcomes.

EMR SUMMARY

Age/Gender : 59 Years/Male

Address :

Discharge Type: Relieved

Admission Date: 15/01/2025 06:49 PM

Diagnosis

ACUTE ON CKD V SECONDARY TO CHRONIC UNCONTROLLED HYPERTENSION COMMUNITY ACQUIRED PNEUMONIA

K/C/O HYPERTENSION

S/P 5 SESSIONS OF DIALYSIS

Case History and Clinical Findings

C/O SOB SINCE 3 DAYS

C/O PEDAL EDEMA SINCE 1 DAY

HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 3 DAYS AGO THEN HE DEVELOPED SHORTNESS OF BREATH INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE FROM GRADE II TO GRADE III-IV MMRC IN 3 DAYS

ASSOCIATED WITH ORTHOPNEA

NOT ASSOCIATED WITH COUGH, FEVER H/O PEDAL EDEMA SINCE 1 DAY

NO H/O DECREASED URINE OUTPUT

NO H/O VOMITINGS, LOOSE STOOLS, NAUSEA, PAIN ABDOMEN NO H/O ITCHING, RASH, CONFUSION

PAST HISTORY:

K/C/O HTN SINCE 20 YEARS

N/K/C/O DM,TB, ASTHMA, EPILEPSY, CVA,CAD, THYROID DISORDERS

PATIENT HAD ABDOMINAL PAIN 20 YEARS BACK AND WAS DIAGNOSED AS RENAL STONES WITH HYPERTENSION AND IS ON STAMLO BETA 5 SINCE 20 YEARS

PERSONAL HISTORY:

DIET-MIXED

APPETITE- DECREASED

BOWEL AND BLADDER MOVEMENTS- REGULAR ADDICTIONS:

NO ADDICTIONS GENERAL EXAMINATION:

PALLOR PRESENT

EDEMA OF FEET PRESENT

NO ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY BP:140/100MMHG

PR:88BPM RR:18CPM SPO2:98%@ RA

SYSTEMIC EXAMINATION:

CVS:S1 S2 HEARD ,NO MURMURS

RS:BAE PRESENT, NVBS PRESENT B/L DIFFUSE CREPTS PRESENT P/A:SOFT,NT, NO ORAGANOMEGALY,BOWEL SOUNDS HEARD CNS: NFND

COURSE IN THE HOSPITAL :

PATIENT WAS ADMITTED WITH THE ABOVE SAID COMPLAINTS AND NECESSARY INVESTIGATIONS WERE DONE. THERE WAS MARKED ELEVATION IN TOTAL LEUCOCYTE COUNT AND APPROPRIATE ANTIBIOTIC WAS INITIATED AND FURTHER OTHER SYMPTOMATIC TREATMENT WAS GIVEN. THERE WAS DERANGEMENT OF RENAL PARAMETERS AND USG ABDOMEN SHOWED B/L GRADE 3 RENAL PARENCHYMAL CHANGES AND WAS DIAGNOSED AS CHRONIC KIDNEY DISEASE AND WAS TAKEN UP FOR HEMODIALYSIS. CENTRAL LINE WAS INSERTED IN RIGHT JUGULAR VEIN AND PATIENT WAS DIALYSED WITH ONE UNIT PRBC TRANSFUSION. PATIENT IMPROVED SYMPTOMATICALLY . FURTHER THREE MORE DIALYSIS WERE DONE AND ONE MORE UNIT PRBC TRANSFUSION WAS ALSO DONE.PATIENT IS THEN DISCHARGED IN A HEMODYNAMICALLY STABLE CONDITION AND WAS ADVISED TO REVIEW FOR FURTHER MAINTAINENCE HEMODIALYSIS.

DIALYSIS DATES 15/1/25

16/1/25

17/1/25

18/1/25

19/1/25

Investigation

CBP HB TC N L E M B PLT SMEAR RFT UR CR UA CA+2 P NA+ K+ CL- HIV HBSAG HCV BLOOD GROUP : ARH TYPING : POSITIVE (+VE)

RBS ON 15/1/25- 143 MG/DL HEMOGRAM ON 15/1/25

HAEMOGLOBIN 7.5 gm/DLTOTAL COUNT 15,000 cells/cumm NEUTROPHILS 84 %

LYMPHOCYTES 10 %EOSINOPHILS 01 % MONOCYTES 05 % BASOPHILS 00 %PCV 21.1 vol % M C V 83.4 fl M C H 29.6 pg. M C H C 35.5 % RDW-CV 15.0 % RDW-SD 46.6 fl RBC COUNT 2.53

millions/cumm PLATELET COUNT 2.51 lakhs/cu.mm SMEARRBC Normocytic normochromic Light Microscopy WBC Within normal limits Light Microscopy PLATELETS Adeqaute Light Microscopy HEMOPARASITES No hemoparasites seen Light Microscopy IMPRESSION Normocytic normochromic anemia with neutrophilic leukocytosis

CUE on 15/1/25

COLOUR Pale yellow APPEARANCE Clear REACTION Acidic SP.GRAVITY 1.010 ALBUMIN +++ SUGAR trace BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 5-6 EPITHELIAL CELLS 3-4 RED BLOOD CELLS Nil CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS Absent Others Nil

SERUM IRON 0n 15/1/25 48 ug/dl HEMOGRAM 16.1.25

HAEMOGLOBIN 8.2 gm/dl TOTAL COUNT 16,200 cells/cumm NEUTROPHILS 92 % LYMPHOCYTES 05 % EOSINOPHILS 00 % MONOCYTES 03 % BASOPHILS 00 % PCV 24.3 vol % M C V 80.7 fl M C H 27.3 pgM C H C 33.8 %RDW-CV 13.4 % RDW-SD 42.7 fl RBC COUNT 3.01

millions/cumm PLATELET COUNT 2.19 lakhs/cu.mm SMEARRBC Normocytic normochromic Light Microscopy WBC Increased on smear Light Microscopy PLATELETS Adequate in number and distribution Light Microscopy Hemoparasites No hemoparasites seen Light Microscopy IMPRESSION Normocytic normochromic Anemia with neutrophilic leucocytosis

HEMOGRAM ON 17/1/25

HAEMOGLOBIN 7.1 gm/dl TOTAL COUNT 10,700 cells/cumm NEUTROPHILS 78 % LYMPHOCYTES 17 % EOSINOPHILS 01 % MONOCYTES 04 % BASOPHILS 00 % PCV 21.2 vol % M C V 81.5 fl M C H 27.3 pg M C H C 33.5 % RDW-CV 13.7 % RDW-SD 43.2 fl RBC COUNT 2.60

millions/cumm PLATELET COUNT 2.19 lakhs/cu.mm SMEAR RBC Normocytic normochromic anemia Light Microscopy WBC With in normal limits Light Microscopy PLATELETS Adequate in number and distribution Light Microscopy HEMOPARASITES No hemoparasites seen Light Microscopy IMPRESSION Normocytic normochromic anemia

RBS ON 17/1/25- 126 mg/dl.

HEMOGRAM ON 18/1/25

HAEMOGLOBIN 8.9 gm/dl TOTAL COUNT 12,900 cells/cumm NEUTROPHILS 78 %

LYMPHOCYTES 15 % EOSINOPHILS 02 % MONOCYTES 05 % BASOPHILS 00 % PCV 26.1 vol % M C V 82.4 fl M C H 27.9 pg M C H C 33.9 %RDW-CV 13.8 % RDW-SD 43.9 fl RBC COUNT 3.17

millions/cumm PLATELET COUNT 2.58 lakhs/cu.mm SMEARRBC Normocytic normochromic Light MicroscopyWBC Increased on smear Light Microscopy PLATELETS Adequate in number and distribution Light Microscopy HEMOPARASITES No hemoparasites seen Light Microscopy IMPRESSION Normocytic normochromic anemia with leucocytosis

HEMOGRAM ON 19/1/25

HAEMOGLOBIN 9.8 gm/dl TOTAL COUNT 13,100 cells/cumm NEUTROPHILS 81

%LYMPHOCYTES 13 % EOSINOPHILS 01 % MONOCYTES 05 % BASOPHILS 00 % PCV 28.8 vol

% M C V 83.1 fl M C H 28.2 pg M C H C 34.0 % RDW-CV 13.6 % RDW-SD 43.4 fl RBC COUNT 3.46

millions/cumm PLATELET COUNT 2.86 lakhs/cu.mm SMEARRBC Normocytic normochromic anemia Light Microscopy WBC increased in count Light Microscopy PLATELETS Adequate in number and distribution Light Microscopy HEMOPARASITES No hemoparasites seen Light Microscopy IMPRESSION Normocytic normochromic anemia with neutrophilic leukocytosis .

LIVER FUNCTION TEST (LFT) 15-01-2025 07:12:PMTotal Bilurubin 0.50 mg/dl Direct Bilurubin 0.15 mg/dl SGOT(AST) 28 IU/LSGPT(ALT) 17 IU/LALKALINE PHOSPHATASE 102 IU/LTOTAL

PROTEINS 5.0 gm/dl ALBUMIN 2.84 gm/dl A/G RATIO 1.31

RFT 15-01-2025 07:12:PMUREA 168 mg/dlCREATININE 11.5 mg/ dl Uric ACID 5.6

mmol/LCALCIUM 8.3 mg/dl PHOSPHOROUS 4.9 mg/dl SODIUM 135 mmol/LPOTASSIUM 5.2

mmol/L.CHLORIDE 106 mmol/L Anti HCV Antibodies - RAPID 15-01-2025 07:12:PM Non Reactive HBsAg-RAPID 15-01-2025 07:12:PM Negative COMPLETE URINE EXAMINATION (CUE) 15-01- 2025 07:12:PMCOLOUR Pale yellow APPEARANCE Clear REACTION Acidic SP.GRAVITY

1.010ALBUMIN +++SUGAR Bile SALTS Nil BILE PIGMENTS Nil PUS CELLS 5-6EPITHELIAL

CELLS 3-4RED BLOOD CELLS Nil CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS

Absent OTHERS Nil

RFT 15-01-2025 11:31:PM UREA 106 mg/dl CREATININE 7.2 mg/ dl Uric ACID 3.0 mmol/LCALCIUM

8.3 mg/dl PHOSPHOROUS 3.6 mg/dl SODIUM 139 mmol/LPOTASSIUM 3.7 mmol/L.CHLORIDE 105

mmol/LRFT 16-01-2025 10:50:PM UREA 94 mg/dl CREATININE 6.5 mg/dl URIC ACID 2.5

mmol/LCALCIUM 8.4 mg/dl PHOSPHOROUS 3.9 mg/dl SODIUM 138 mmol/LPOTASSIUM 3.5

mmol/L.CHLORIDE 102 mmol/L

ABG 18-01-2025 12:22: AM 7.36PCO2 16.6PO2 48.4 HCO3 9.3St .HCO3 13.0 BEB -14.5BEecf -

15.2TCO2 19.9O2 Sat 86.0O2 Count 10.5RFT 18-01-2025 12:22:AM UREA 74 mg/dl creatinine

5.4 mg/dl URIC ACID 2.2 mmol/LCALCIUM 9.2 mg/dl PHOSPHOROUS 3.2 mg/dl SODIUM 137

mmol/LPOTASSIUM 3.7 mmol/L.CHLORIDE 102 mmol/L

RFT 19-01-2025 11:12:PM UREA 54 mg/dl CREATININE 5.2 mg/ dl Uric ACID 2.0 mmol/LCALCIUM

9.0 mg/dl PHOSPHOROUS 2.8 mg/dl SODIUM 138 mmol/LPOTASSIUM 3.9 mmol/L.CHLORIDE 101

mmol/L

ULTRASOUND DONE ON 15/1/25

GRADE III RPD CHANGES IN B/L KIDNEYS RIGHT RENAL CORTICAL CYSTS

MILD FREE FLUID IN PELVIS B/L PLEURAL EFFUSION

2D ECHO REPORT DONE ON 16/1/25 CONCENTRIC LVH+ [1.40 CMS]

NO RWMA

MILD TR+ WITH PAH [ RSVP= 42+5= 47 MMHG] [ECCENTRIC TR+/MR+] MILD PR+ TRIVIAL MR+; MILD AR+ [AR- PHT-728 ML/SEC]

SCLEROTIC AV; NO AS/MS ; IAS- INTACT EF= 63% GOOD LV SYSTOLIC FUNCTION GR II DIASTOLIC DYSFUNCTION

IVC SIZE 1.27 CMS COLLAPSING MINIMAL PE+; NO LV CLOT

IVS- 1.40 CMS

ESD- 3.28 CMS

EDD- 5.01 CMS

DPW- 1.39 CMS

Treatment Given(Enter only Generic Name)

1. FLUID RESTRICTION <1.5 L/DAY

2. SALT RESTRICTION <2 GM/DAY

3. INJ.PIPTAZ 2.25 GM IV BD FOR 4 DAYS

4. INJ. PAN 40 MG IV OD

5. INJ LASIX 80 MG IV BD

6. T. NICARDIA 20 MG PO TID

7. T.ARKAMINE 0.1 MG PO TID

8. T. SHELCAL CT PO OD

9. T.OROFER XT PO OD

10. T.NODOSIS 500 MG PO OD

11. CAP BIO D3 60K IU PO ONCE WEEKLY

12. INJ.EPO 4000 IU S/C ONCE WEEKLY

13. SYP.ASCORYL D 10 ML PO TID

14. SYP CREMAFFIN 20 ML PO BD

15 STRICT I/O CHARTING

16. MONITOR VITALS AND INFORM SOS DIALYSIS DATES

15/1/25

16/1/25

17/1/25

18/1/25

19/1/25

Advice at Discharge

1. FLUID RESTRICTION <1.5 L/DAY

2. SALT RESTRICTION <2 GM/DAY

3. TAB PAN 40 MG IV OD

4. TAB LASIX 80 MG IV BD

5. T. NICARDIA 20 MG PO TID

6. T.ARKAMINE 0.1 MG PO TID

7. T. SHELCAL CT PO OD

8. T.OROFER XT PO OD

9. T.NODOSIS 500 MG PO OD

10. CAP BIO D3 60K IU PO ONCE WEEKLY

11. INJ.EPO 4000 IU S/C ONCE WEEKLY

13. SYP.ASCORYL D 10 ML PO TID

14. SYP CREMAFFIN 20 ML PO BD

Follow Up

REVIEW SOS OR REVIEW AFTER 3 DAYS AT NEPHROLOGY OPD

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language

SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY

Discharge Date Date:20/1/25 Ward: AMC

Unit: NEPHROLOGY