Case 3 - A 56 M with Pedal edema , SOB and Altered sensorium

 A 56 year old male patient daily waged labourer and farmer by occupation presented with 

c/o altered sensorium since 2 days  

decreased urine output, pedal edema, and shortness of breath since 4 days.

Patient was apparently alright 16years back later he developed jaundice for which patient initially took some herbal medication and as the patient did not felt any improvement he went to local doctor and took some medication. Then he was incidentally found to have low platelets for which SDP was done ( yellow coloured blood as in terms of patient) and diagnosed with diabetes and adviced OHA.

4-5 years back patient feels generalised weakness, easy fatigue, and loss of apatite which made him to stop his daily labour work and started taking rest in home.

Since 1 year his symptoms are aggravating.

In January 2020

Patient developed swelling in rt gluteal Region and was diagnosed with right gluteal abcess for which Incision and drainage was performed. He also had pedal edema and SOB for which dialysis was initiated. He was diagnosed with denovo hypertension and on tab. Nicardia 10mg. His labs revealed 

Sr.urea = 116

Sr creat = 6.7

Rt.renal calculi 

Cholilithiasis @ 2-4mm largest.


In April 2020 patient was admitted for MHD as he was on irregular dialysis. Urea = 41 , creat = 4.9

In July 2020 as patient came for dialysis, treating doctors found his sugars are not under control,

Then added tab glimipride1mg + metformin 500mg. Cholilithiasis with largest 5mm. His Sr.urea 206, creat 11.6, pH 7.27, Hco3- 9.1 and Hb - 5.5

After few dialysis his labs @ discharge was urea = 57, creat = 4.1 and Hb = 6.8.

In August 2020 

Patient suddenly developed altered sensorium ( on and off) with green coloured vomiting and Anasarca. Cholilithiasis with largest 7mm , mild ascitis and Grade 2 RPD changes. Urea = 62, creatinine =6.7

In November 2020

Patient presented with altered sensorium, anasarca, hypotension.

Bp not recordable at the time of presentation.

Patient devolved this episode of altered sensorium from yesterday night around 2am. As he got up from sleep and started talking irrelavent with altered behaviour.

Pedal edema and SOB since 1 week. Last session of dialysis was on 30 October 2020.

Now his RFT Shows Sr.urea = 190, creat = 10.6 and Sodium is 122 ( ?Chronic hyponatremia)

O/E : Pt drowsy but aurosable.

GCS 15/15








Pedal edema 





CBP :

 Hb 2.5 gm/dl

TLC 4200 cells/mm3

RBC 0.91 million/mm3

Platelets 20000 /mm3

APTT 40sec

PT 20 sec

INR 1.45


Summary:

A 56M patient with Diabetes since 16years , hypertension since 1 year with k/c/o CKD on MHD, Rt renal calculi and cholilithiasis (since 1year )  with Altered sensorium, anasarca, anemia, thrombocytopenia, and chronic hyponatremia.



SERIES OF MEDICAL EVENTS : 


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