Aki on ckd

 A 70 YEAR OLD MALE WITH SOB AND SWELLING, DISCHARGE FROM RT. LOWER LIMB( CELLULITIS) 


Chief complaint :

• Altered sensorium , since 2 days

• SOB grade IV , since 5 days

• Pedal edema grade III, since 7 days

• Rt. Lower limb cellulitis, since 7 days


History of presenting illness:

• A 70 yr old male, farmer by occupation, was apparently asymptomatic 2 yrs back. 

• Had h/o CVA 2 yrs back and for which he used medications for 4 months, and stopped. 

• k/c/o HTN since 2 yrs and is on regular medication

• k/c/o CKD since 2 yrs and is on conservative management

•1 1/2  yr back, had h/o trauma - Lt. femur

• 1 yr back - Lt. arm # , for which casting was done

• 15 days back, he had h/o trauma to Rt. Lower limb which gradually progressed to rt. Lower limb cellulitis

• c/o pedal edema grade - III, pitting type, relieved on medication

• c/o SOB grade II-III, progressed to grade IV

• H/O chest pain and chest tightness

• No c/o palpitations, syncopal attacks

• decreased urine output + , facial puffiness +

• No c/o orthopnoea, PND, burning micturition

History of past illness:

• No h/o DM, CAD, TB, epilepsy, asthma


Treatment history:

• Has a treatment history of HTN since past 2 yrs

• Has no treatment history of DM, CAD, asthma, TB, antibiotics, hormones, chemoradiation


Personal history:

• Farmer by occupation

• Has lost / decreased appetite

• Follows a mixed diet

• Has regular bowel habits

• Has decreased frequency of micturition

• Has no h/o allergies

Family history:

• Has no family history of DM, HTN, heart disease, stroke, cancers, TB, asthma. 

Physical Examination:

• Pallor - yes
• Cyanosis - no
• Lymphadenopathy - no
• Clubbing of toes/fingers - no
• Oedema of feet - yes

Vitals :

• Temperature : 95.7 °F
• Pulse rate : 92 / min
• Respiratory rate : 24times /min
• BP : 11/70 mmHg
• SPO2 - 98%
• GRBS : 104 mg

Systemic Examination:

A. Cardiovascular system

• No thrills and no cardiac murmurs 
• S1, S2 heard

B. Respiratory system

• Dyspnoea present
• No wheeze 
• Trachea position - central
• Breath sounds - vesicular
• BAE +

C. Abdomen

• Shape of abdomen - scaphoid
• No tenderness, no palpable mass
• Normal hernial orifices
• No free fluid, no bruits present
• Liver, spleen are not palpable
• Normal bowel sounds present
• soft and now tender

D. Central nervous system

• Level of consciousness- drowsy 1 arousable
• Speech - normal
• No neck stiffness and no kerning's sign
• Glasgow scale - 15/15

PROVISIONAL DIAGNOSIS:

       ?    AKI ON CKD
        ?   UREMIC ENCEPHALOPATHY
        ? RT. LOWER LIMB CELLULITIS



Investigations:

ON 19.7.21













ON 20.7.21






ON 21.7.21






On 26.7.2021:







Treatment :

1. INJ. LASIX  40mg IV/BD
2. NEB T DUOLIN 8th hourly
                Budecort 12th hourly
3. TAB. NODOSIS 550mg PO/BD
4. TAB SHELLCAL 500 mg PO/OD
5. TAB. CLINDIPINE 10mg PO/OD
6. INJ. PIPTAZ 2.25gm/IV /QID /8th hourly
7.T. ECOSPRIN 75mg/PO/HS
8. T. ATORVAS 20mg/PO/HS
9. BP/PR/RR/SPO2 charting 4th hourly
10. GRBS charting 6th hourly
11. STRICTLY I/O CHARTING

On cross consultation with surgery dept. 

On inspection: ( of rt. leg) 

• Reddish, wrinkling of skin is present
• ulcer size  3×4×7 cms
               Margin sloping
               Surrounding skin erythematous
               No line of demarcation seen
• present over the rt. Shin of tibia, discharging pus
• oedema extending from toes to skin above knees
• no necrolic pouches present on toe nails

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