46 yr male with vomiting

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Case presentation:

46 yr old male k/c/o DM since 12 yrs and HTN since 8 yrs who is a pastor came  to casualty on 23rd August with complaints of vomiting since 4 days.

he was apparently asymptomatic 2yrs back 

developed fever and weakness for which he had consulted a local doctor who gave him multivitamin syrup and iron tablets.

He developed sweating, giddiness and lost consciousness after using those medications.

he was taken to nalgonda hospital where they had performed few tests which revealed  he had a kidney problem with raised urea and creatinine levels.The doctor advised for dialysis.

patient refused and took some other medications for 1yr,

 • 10months back-

Pt developed symptoms of decreased urine output and vomiting 3-4 episodes/day.

so he came to our hospital and dialysis was done.

he had no complaints after that dialysis sitting untill

 • 4 days back-

vomiting 3-4 episodes/day,no history of pedal edema, shortness of breath,

raised urea and creatinine levels,

admitted here for dialysis.

past history-h/o cellulitis 3yrs back 

personal history-

diet-mixed

appetite-normal

sleep-adequate

bowel and bladder-regular

no Addictions

drug history-allergic to iron tablets

treatment-on erythropoietin injection once a week, stamlo 5mg od,nodosis bd and HAI bd

O/E-

Pt is conscious, coherent and cooperative

pallor-present

no signs of icterus, cyanosis, clubbing,koilonychia, lymphadenopathy

Skin changes on elbows,thighs and legs.

PRURIGO NODULARIS 

26th August- Dermatology opinion taken-chronic eczema

vitals-

afebrile

BP-140/80

pulse-86

rr-20

CVS-S1S2 heard

RS-BAE present

P/A-soft ,non tender

CNS-normal

Input and output-

24th August

 input -1500ml approx

output-around 550ml

25th August

input-1500ml approx

output-around 500 ml

26th August

input-1000ml

output-200ml

         

INVESTIGATIONS-

Ultrasound-

RFT-

ABG-

Diagnosis- known case of CKD with HTN and DM

TREATMENT-

1.tab.LASIX 20 mg po /BD

2.tab.NICARDIA10mg po/BD

3.tab.NODOSIS 500mg po/ BD

4.inj.ERYTHROPOIETIN s/c weekly twice

Donot give packed RBC (transfusion)as the erythropoietin further decreases and body becomes transfusion dependent

5.inj.HAI s/c according to sliding scale

Give only 80% of calculated dose of insulin,as it is also excreted through kidney.

6.tab.SHELCAL po /OD

Prefer tab.sevelamer over ca and vitd3

Dialysis was done on 24th and 25th August ,

Transplantation is preferred with maintanence on steroids+tacrolimus+mycophenolate+azathioprine+sirolimus(non nephrotoxic,so preferred drug)

Reports on 26th August-