CASE OF 55 YR OLD MALE WITH DIABETIC NEPHROPATHY WITH UTI
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
CHIEF COMPLAINTS:
- Loss of appetite since 1 week
- B/L pedal edema since 1 week
- Facial puffiness since 1 week
- Abdominal discomfort since 1 week
- Decreased urine output since 3 days
- Burning micturition since 3 days
- Shortness of breath since 1 day
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 week back when he used to eat 4 meals a day but gradually reduced to 2 idlis/day .He had insidious onset of B/L pedal edema which is of pitting type, gradually progressive till knee followed by facial puffiness and abdominal discomfort.
From 3 days patient is having decreased urine output (initially used to void 4 times /day to 1 time /day) and burning micturition.
History of shortness of breath , even at rest since 1 day
Patient also complains of neck pain since yesterday night
There was
- No h/o fever, vomitings, loose stools
- No h/o pain abdomen
- No h/o orthopnea and PND
PAST HISTORY :
20 years back he was diagnosed with TYPE 2 DM and HTN on routine checkup and was on regular medication
He was on TELMISARTAN 40 mg since 20 years
For DM he was on ( ? Tab GLIMI ) since 20 years
PERSONAL HISTORY
Mixed diet
Sleep adequate
Appetite - decreased
Bowel movements regular
Decreased urine output since 3 days
Addictions - Consumes alcohol occasionally
FAMILY HISTORY
No history of DM, hypertension, CVA, CAD, Asthma, Thyroid disorders and epilepsy in the family.
GENERAL EXAMINATION
Patient is conscious, coherent, co-operative.
Moderately built and moderately nourished
B/L pedal edema (pitting type ) present
No pallor, cyanosis, clubbing,icterus koilonychia and lymphadenopathy.
On examination an Ulcer noted over the back of right leg . 20 days back Patient had mosquito bite over the back of right leg...after 4 days of bite there was pus discharge along with pain for which he went to a local RMP & took medication (unknown), but pain didnt subside .
VITALS AT ADMISSION
Temperature- Afebrile
Pulse rate- 96 bpm
Respiratory Rate- 22 cpm
BP-180/110 mmHg
SPO2 at room air- 98%
GRBS 120 mg/dl
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM:
Inspection:
Chest wall is bilaterally symmetrical.
No precordial bulge
No visible pulsations, engorged veins, scars, sinuses
Palpation:
JVP: normal
Apex beat: felt in the left 5th intercostal space in the mid clavicular line.
Auscutation:
S1, S2 heard , No murmurs
RESPIRATORY SYSTEM-
Position of trachea: central
Bilateral air entry +
Normal vesicular breath sounds - heard
No added sounds.
PER ABDOMEN:
Abdomen is soft, distended and non tender.
No organomegaly.
Bowel sounds heard.
No palpable mass present
CENTRAL NERVOUS SYSTEM:
Patient is Conscious
Speech: normal
No signs of Meningeal irritation
Motor & sensory system: normal
Reflexes: present
Cranial nerves: intact
INVESTIGATIONS :
ON DAY 14/08/2021
CXR
ECG
HEMOGRRAM
CUE
LFT
SERUM CREATININE
6.5 mg/dl
BLOOD UREA
153 mg/dl
ABG
SERUM ELECTROLYTES
URINARY ELECTROLYTES
RBS
114 mg/dl
SERUM IRON
78 micro gm /dl
USG ABDOMEN
15/08/2021
FBS
137 mg/dl
BLOOD UREA
161 mg/dl
SERUM CREATININE
6.8 mg/dl
16/08/2021
BLOOD UREA
173 mg/dl
SERUM CREATININE
7.9 mg/dl
SERUM ELECTROLYTES
FBS
133 mg/dl
PLBS
162 mg/dl
24 HOUR URINARY PROTEIN
24 HRS CREATININE (URINE)
CXR AFTER CENTRAL LINE
USG CHEST
17/08/2021
CXR - PA VIEW
FEVER CHARTING
CUE
Plenty of pus cells present
USG ABDOMEN
19/08/2021
RFT
urea - 115 mg/dl
Creatinine - 6.4mg/dl
HEMOGRAM
22/08/2021
HEMOGRAM
Hb - 11.7
Tc - 28,600
Neutrophils -86
Lymp -07
Pcv - 32.6 %
Rbc - 3.74 millions/cumm
Plt - 2.61 lakhs/cumm
RFT
Urea - 108 mg/dl
Se.creatinine - 7.2 mg/dl
Na - 128 meq/l
Ph - 7.0 mg/dl
Cl - 88 meq/l
K -4.9 meq/l
URINE C/S
PROVISIONAL DIAGNOSIS
? DIABETIC NEPHROPATHY WITH UTI
K/C/O TYPE 2 DM & HTN SINCE 20 YEARS
TREATMENT:
DAY 0
1. Tab NIFEDIPINE 20 mg PO /stat
2. Inj LASIX 40 mg IV/BD
3. GRBS charting 6th hourly
4. Strict I/O charting
5. 2nd hourly BP charting
6. Inj HAI S/C according to sliding scale
DAY 1
SOAP NOTES :
SUBJECTIVE:
C/O - B/L pedal edema
Facial puffiness
Decreased urine output
Shortness of breath
Burning micturition
Hematuria
OBJECTIVE:
Temperature - Afebrile
Bp - 150/90 mm hg
PR - 75 bpm
RR - 20 cpm
GRBS - 146 mg/dl
ASSESSMENT:
? Diabetic nephropahy
K/c/o Type 2 DM & HTN (since 20 years)
PLAN OF CARE:
1. Fluid restriction < 2L/day
Salt restriction < 2g/day
2. Inj . LASIX infusion 5 Amps + 30 ml NS @ 5 ml/hr
3. GRBS charting 6th hourly
4. BP Charting 4th hourly
5. Strict I/O charting
6. Tab.NICARDIA 20 mg PO/TID
7. Syp CITRALKA PO/BD 15 ml in half glass of water
DAY 2
SOAP NOTES:
SUBJECTIVE:
C/O - B/L pedal edema
Facial puffiness
Decreased urine output
Shortness of breath
Burning micturition
Ulcer over the back of right leg
OBJECTIVE:
Temperature - Afebrile
Bp - 170/100 mm hg
PR - 82 bpm
RR - 19 cpm
GRBS - 89 mg/dl
ASSESSMENT:
? Diabetic nephropahy
K/c/o Type 2 DM & HTN (since 20 years)
PLAN OF CARE:
Hemodialysis Done at morning 7 AM - 1st session
1. Fluid restriction < 2L/day
Salt restriction < 2g/day
2.Tab.MET-XL 25 mg PO/OD
3.Tab.NICARDIA 20 mg PO/TID
4.Syp CITRALKA PO/BD 15 ml in half glass of water
5. Tab ULTRACET 1/2 tab QID
6. GRBS charting 6th hourly
7. BP Charting 4th hourly
8. Strict I/O charting
DAY 3
SOAP NOTES:
SUBJECTIVE:
C/O - B/L Pedal edema
Decreased urine output
Burning micturition
Ulcer over the back of right leg
SOB Resolved
Facial puffiness resolved
OBJECTIVE:
Temperature - Afebrile
Bp - 130/80 mm hg
PR - 62 bpm
RR - 17 cpm
GRBS - 164 mg/dl
ASSESSMENT:
? Diabetic nephropahy
K/c/o Type 2 DM & HTN (since 20 years)
PLAN OF CARE:
1. Fluid restriction < 2L/day
Salt restriction < 2g/day
2.Tab.MET-XL 25 mg PO/OD
3.Tab.NICARDIA 20 mg PO/TID
4.Syp CITRALKA PO/BD 15 ml in half glass of water
5. Tab ULTRACET 1/2 tab QID
6. E/D NEPATOP TID ( In fundoscopy mild NPDR changes noted in both eyes)
7. GRBS charting 6th hourly
8. BP Charting 4th hourly
9. Strict I/O charting
10. Inj PIPTAZ
DAY 4
SOAP NOTES:
SUBJECTIVE:
C/O - B/L Pedal edema
Decreased urine output
Burning micturition
Vomitings (2 episodes)
SOB resolved
Facial puffiness resolved
OBJECTIVE:
Temperature - Afebrile
Bp - 150/90 mm hg
PR - 82 bpm
RR - 17 cpm
GRBS - 143 mg/dl
ASSESSMENT:
? Diabetic nephropahy with UTI
K/c/o Type 2 DM & HTN (since 20 years)
PLAN OF CARE:
Hemodialysis (2nd session) done today morning
1. Fluid restriction < 2L/day
Salt restriction < 2g/day
2.Inj PIPTAZ 2.25 gm/iv/TID
3.Tab.MET-XL 25 mg PO/OD
4.Tab.NICARDIA 20 mg PO/TID
5.Syp CITRALKA PO/BD 15 ml in half glass of water
6. Tab ULTRACET 1/2 tab QID
7. E/D NEPATOP TID ( In fundoscopy mild NPDR changes noted in both eyes)
8. GRBS charting 6th hourly
9. BP Charting 4th hourly
10. Strict I/O charting
DAY 5
SOAP NOTES:
SUBJECTIVE:
C/O - B/L Pedal edema
Decreased urine output
Abdominal tightness
OBJECTIVE:
Temperature - Afebrile
Bp - 130/80 mm hg
PR - 80 bpm
RR - 16 cpm
GRBS - 148 mg/dl
I/O - 1000ml/60 ml (24 hrs)
ASSESSMENT:
? Diabetic nephropahy with UTI
K/c/o Type 2 DM & HTN (since 20 years)
PLAN OF CARE:
Hemodialysis 2 sessions done
1. Fluid restriction < 2L/day
Salt restriction < 2g/day
2.Inj PIPTAZ 2.25 gm/iv/TID
3.Tab.MET-XL 25 mg PO/OD
4.Tab.NICARDIA 20 mg PO/TID
5. Inj LASIX 40 mg/BD
6. IVF 500 ml NS @ 75 ml/hr
7.Syp CITRALKA PO/BD 15 ml in half glass of water
8. Tab ULTRACET 1/2 tab QID
9. E/D NEPATOP TID ( In fundoscopy mild NPDR changes noted in both eyes)
10. GRBS charting 6th hourly
11. BP Charting 4th hourly
12. Strict I/O charting
DAY 6
SOAP NOTES:
SUBJECTIVE:
C/O - B/L Pedal edema
Decreased urine output
Abdominal tightness
OBJECTIVE:
Temperature - Afebrile
Bp - 150/80 mm hg
PR - 82 bpm
RR - 16 cpm
GRBS - 150 mg/dl
I/O - 1500ml/100 ml (24 hrs)
ASSESSMENT:
? Diabetic nephropahy with UTI
K/c/o Type 2 DM & HTN (since 20 years)
PLAN OF CARE:
Hemodialysis 2 sessions done
1. Fluid restriction < 2L/day
Salt restriction < 2g/day
2.Inj PIPTAZ 2.25 gm/iv/TID
3.Tab.MET-XL 25 mg PO/OD
4.Tab.NICARDIA 20 mg PO/TID
5. Inj LASIX 40 mg/BD
6. IVF 500 ml NS @ 75 ml/hr
7.Syp CITRALKA PO/BD 15 ml in half glass of water
8. Tab ULTRACET 1/2 tab QID
9. E/D NEPATOP TID ( In fundoscopy mild NPDR changes noted in both eyes)
10. GRBS charting 6th hourly
11. BP Charting 4th hourly
12. Strict I/O charting
DAY 7 :
SOAP NOTES:
SUBJECTIVE:
C/O - B/L Pedal edema
Decreased urine output
OBJECTIVE:
Temperature - Afebrile
Bp - 150/80 mm hg
PR - 80 bpm
RR - 16 cpm
GRBS - 144 mg/dl
I/O - 1000ml/ 50ml (24 hrs)
ASSESSMENT:
? Diabetic nephropahy with UTI
K/c/o Type 2 DM & HTN (since 20 years)
PLAN OF CARE:
Hemodialysis 2 sessions done
1. Fluid restriction < 2L/day
Salt restriction < 2g/day
2.Inj PIPTAZ 2.25 gm/iv/TID
3.Tab.MET-XL 25 mg PO/OD
4.Tab.NICARDIA 20 mg PO/TID
5. Inj LASIX 40 mg/BD
6. IVF 500 ml NS @ 75 ml/hr
7.Syp CITRALKA PO/BD 15 ml in half glass of water
8. Tab ULTRACET 1/2 tab QID
9. E/D NEPATOP TID ( In fundoscopy mild NPDR changes noted in both eyes)
10. GRBS charting 6th hourly
11. BP Charting 4th hourly
12. Strict I/O charting
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