66 year old daily wage worker-

 

INTRODUCTION-

This is online E logbook to discuss our patient’s de-identified health data shared after taking his 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

66-year-old male came to hospital with complaints of-

Chief complaints- lower limb pitting edema, upper limb edema and fascial puffiness since 5 days

History of present illness- apparently asymptomatic 5 days back, then developed lower limb pitting edema progressing to upper limb. No H/O fever, vomiting, loose stool, orthopnea, PND

History of past illness- Apparently asymptomatic 8 years ago, in 2013 he came to our hospital with complaints of cellulitis and oliguria. Patient was admitted and treated with skin graft surgery. At time of admission, serum creatinine and blood urea were high along with hypertension. He got 3 sessions of hemodialysis. 3 months ago, he took 3 tablets for hypertension (prazosin?), smoked a cigarette developing right side hemiparesis. He went to a hospital in Khammam with complaints of right hemiparesis, slurring of speech, deviation of mouth which recovered within 1 week.

General examination-

·       Pallor present

·       Cyanosis absent

·       Icterus absent

·       Clubbing absent

·       Lymphadenopathy absent

·       Pedal edema present



·       Malnutrition absent

·       Dehydration absent

·       Temperature- 98.4 F

·       Pulse rate- 75 BPM

·       Respiratory rate -24/min

·       BP- 220/130 mmHg

·       SpO2- 98%

·       GRBS- 127 mg%

Treatment history-

·       Hypertension- prazosin

Systemic examination-

·       CVS-

o   No thrills

o   S1, S2 +

o   No murmurs

·       CNS-

o   Conscious

o   No slurring of speech

o   No neck stiffness

o   Kernings signs absent

o   GCS- 15/15

o   Motor system- normal

o   Sensory system- normal

·       RS-

o   Dyspnea absent

o   Wheeze absent

o   Trachea central

o   Vesicular breath sounds

·       ABD-

o   Scaphoid

o   Tenderness absent

o   No palpable mass

o   Normal hernial orifices

o   No free fluid

o   No bruits

o   Liver- nonpalpable

o   Spleen- nonpalpable

o   Bowel sounds present

Investigations-

ECG- normal-



MRI Brain- ischemia and infarctions-



HBA1C, GRBS- normal-



Ultrasound abdomen- renal parenchymal changes and prostamegaly.




Serum creatinine- raised-



Revealing high serum creatinine, prostomegaly, renal parenchymal changes and infarcts in the brain.

Provisional diagnosis- hypertensive urgency, anemia, anasarca, and AKI on CKD

Treatment-

·       1/10/21-

·       B+ PRBC transfusion

·       Fluid restriction- <1.5l/day

·       Salt restriction- <2g/day

·       Inj. Lasix 40mg IV

·       Tab. Nicardia 20mg  

·       Tab. Clopidogrel

·       Tab. Atorvastatin

·       BP monitoring for 1 hr

·       2/10/21

o   Inj. Lasix

o   Tab. Nicardia

o   Tab. Clopridogel

o   Tab. Atorvastatin

o   Tab. Arkamine

o   Tab. Met-xl

o   Tab. Ecosporin

·       3/10/21-

o   Tab ultracet

o   Tab. Cilnidipine

o   Inj. Lasix

o   Tab. Nicardia

o   Tab. Clopridogel

o   Tab. Atorvastatin

·       4/10/21-

o   Tab ultracet

o   Tab. Cilnidipine

o   Inj. Lasix

o   Tab. Nicardia

o   Tab. Clopridogel

o   Tab. Atorvastatin

·       5/10/21-

o   Tab ultracet

o   Tab. Cilnidipine

o   Inj. Lasix

o   Tab. Nicardia

o   Tab. Clopridogel

o   Tab. Atorvastatin

·       7/10/21-

o   Tab ultracet

o   Tab. Cilnidipine

o   Inj. Lasix

o   Tab. Nicardia

o   Tab. Clopridogel

o   Tab. Atorvastatin

 

 

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