General medicine case 5



A 55 years old male patient with bilateral pedal edema


"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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome."


Case:

A 55 year old male patient farmer by occupation with bilateral pedal edema and high fever(associated with chills) since since 12 days.

Date of admission:20/09/2021

History of present illness

Patient was apparently asymptomatic 12 days before the standing illness.Then the patient was presented to the Casualty with bilateral pedal edema and high fever since 12 days.

Patient had pre-renal AKI on CKD secondary to sepsis ( Acute gastroenteritis) with history of surgery to right forearm 2 years back, thrombocytopenia,right gluteal abscess,right upper limb monoparesis.

4 days before the date of admission, patient had fever and bilateral pedal edema and high fever, where the patient was taken to hospital in nalgonda and there was decrease in WBC count.
And was suggested to kims.

Patient had generalized weakness 5 to 6 months back,but still continued his working.

Patient had no c/o SOB, chest pain, palpations,no orthopnea.

Patient c/o giddiness,loss of appetite.

C/o of loose stools 3 days before admission of 10-12 episodes/day for 2 days which has subsided now.
Black stools+ associated with pain abdomen in umbilicus.

No vomitings, headache,cough.

No decreased urine output.

No h/o trauma, seizures.

No previous history of renal issues.

Past history 

No history of DM/HTN/CVA/CAD/Asthma/Epilepsy/TB/Thyroid disorders

The patient had implant in right forearm 2 years back.

Patient suffered COVID-19 4 months back for which treatment was taken and became normal in 15 days.

1 year ago-typhoid and liver issues subsided on taking medications.

No h/o Renal issues.

Personal history 

Diet : mixed
Appetite : lost 
Bowel and bladder : normal 
Addictions: 
Chronic alcoholic (90ml/day)
Chronic chutta smoker.

No h/o known allergies.

Family history

No history of DM/HTN/CVA/CAD/Asthma/TB/thyroid disorders

No similar complaints in the family previously. 

Treatment history

Implant placement in right forearm 2 years back.

Not allergic to known allergies.

General examination

Patient is conscious, coherent and co-operative.

No pallor, no icterus,no cyanosis,no clubbing
No dehydration,no malnutrition.
Oedema present.

Vitals

Bp :110/70 mm hg
PR: 82bpm
Spo2: 99% 
Temperature:afebrile

Systemic examination:

CARDIOVASCULAR SYSTEM:

Inspection:

Chest wall is bilaterally symmetrical.
No precordial bulge.
Palpation:

JVP: normal

Auscutation:
Normal with regular heartbeat

S1, S2 heard
 
No thrills.

No murmurs 

RESPIRATORY SYSTEM-

Position of trachea: central
Normal Bilateral air entry
Wheeze -ve
Dyspnoea -ve
Breath sounds: vesicular.

PER ABDOMEN:

Abodmen is distended. No mass is palpable. 
No tenderness.
No bruits.
Liver: not palpable
Spleen: not palpable
Bowel sounds +ve

CENTRAL NERVOUS SYSTEM:

Level of consciousness:Alert.
Speech: normal.
No signs of meningeal irritation.

Investigations:

20/09/21
Hemogram:
RBC:3.57 millions/cumm
WBC:19,200 cells/cumm
PLATELETS:48,000/cumm.
Hb:11 gm/dl

21/09/21
Hemogram:
RBC:3.69millions/cumm
WBC:19,000cells/cumm
PLATELETS:40,000/cumm.
Hb:11.8 gm/dl

Blood urea:262mg/dl
Serum creatinine:8.3mg/dl

Serum electrolytes:
Na+:128meq/l
K+:3.9meq/dl
Cl-:84meq/dl

Blood group:B+

HIV 1/2 Rapid test:Non-reactive

HbsAg Rapid: Negative

Anti HCV Ab: Negative

22/09/21
Hemogram:
RBC:3.79millions/cumm
WBC:26,000cells/cumm
PLATELETS:72,000/cumm.
Hb:11.8 gm/dl

23/09/21
Hemogram:
RBC:3.76millions/cumm
WBC:16,600cells/cumm
PLATELETS:90,000/cumm.
Hb:11.4 gm/dl

24/09/21
T3:0.66ng/ml
T4:10.37micro gm/dl
TSH:1.58 micro lu/dl

27/09/21
Hemogram:
RBC:3.21millions/cumm
WBC:11,300cells/cumm
PLATELETS:3.22 lakhs/cumm.
Hb:9.8gm/dl

Blood urea:155mg/dl
Serum creatinine:4.3mg/dl

Serum electrolytes:
Na+:136meq/l
K+:4.0meq/dl
Cl-:101meq/dl

LEFT UPPER LIMB POP EYE MUSCLE:


Implant in the right upper limb:

TPR CHART:

ECG:


Provisional diagnosis:

AKI ON CKD SECONDARY TO ACUTE GE.
Fever with thrombocytopenia with bleeding manifestations +ve with unilateral monoparesis.

Treatment plan:

20/09/2021
IVF:NS,RL @ 50 ml/ hr
Inj. Ceftriaxone 1g/iv/bd
Inj. Pan 40mg iv/OD
Inj. Zofer 4mg iv stat

21/09/2021
IVF:NS,RL @ 50 ml/ hr
Inj. Ceftriaxone 1g/iv/bd
Inj. Pan 40mg iv/OD
Inj. Zofer 4mg iv stat
Inj.optineuron 1amp iv OD
Tab.PCM 650mg po sos
Inj.lasix 40mg

22/09/2021
Inj. Pan 40mg iv/OD
Inj. Piptaz 4.5g/iv/stat
Inj. Lasix 40mg iv/bd
Tab. Pcm 650 mg po/sos
Tab. Doxy 100mg po/bd
Tab. Nodosis 500mg po / tid
Tab. Shelcal 500mg po/OD
INJ. Optineuron 1 amp. IV /OD

23/09/2021
Inj. Pan 40mg iv/OD
Inj. Piptaz 4.5g/iv/stat
Inj. Lasix 40mg iv/bd
INJ. Optineuron 1 amp NS IV /OD
Tab. Doxy 100mg po/bd
Tab. Nodosis 500mg po / tid
Tab. Ultracet 500mg po qid
Tab.shellac 500 mg po od

24/09/2021
Inj. Pan 40mg iv/OD
Inj. Piptaz 4.5g/iv/stat
Tab. Pcm 650 mg po/sos
Tab. Nodosis 500mg po / tid
Tab. Ultracet 500mg po qid
Inj. Pan 40mg iv/OD
Inj. Piptaz 4.5g/iv/stat
Tab. Pcm 650 mg po/sos
Tab. Nodosis 500mg po / tid
Inj.Norad @8ml/hr
INJ. Optineuron 1 amp. IV /OD

25/09/2021
Inj. Pan 40mg iv/OD
Inj. Piptaz 4.5g/iv/stat
Tab. Pcm 650 mg po/sos
Tab. Nodosis 500mg po / tid
Tab. Ultracet 500mg po qid
Inj.Norad @8ml/hr

26/09/2021
Inj. Pan 40mg iv/OD
Inj. Piptaz 4.5g/iv/stat
Tab. Nodosis 500mg po / tid
Tab. Ultracet 500mg po qid
Inj.Norad @8ml/hr

27/09/2021
Inj. Pan 40mg iv/OD
Inj. Piptaz 4.5g/iv/stat
Tab. Nodosis 500mg po / tid
Tab. Ultracet 500mg po qid







1.What is the reason for black stools of the patient?
2.How could we identify the warning stage of AKI?
3.Why pottasium sparing drugs and beta-blockers are contra-indicated in AKI???
4.How does AKI affect pottasium???
5.What medications could cause AKI???


















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