A 70-year-old woman from Gouravaram, born into a lower middle-class family, lacked formal education, and was married at 14 in a non-consanguineous union. Having a pleasant childhood with three siblings, she turned to farming for a livelihood, raising two sons and a daughter. Her father's early demise and mother's passing 12 years ago due to old age left an impact. Eight years ago, her husband, facing similar issues as she does now, passed away after dialysis. Knee pain and fatigue led her to cease daily tasks, cared for by her elder son. Recently, she developed shortness of breath, pedal edema, and reduced urine output, initially diagnosed with CKD, and is now experiencing a recurrence after conservative management
.PATIENT WAS BROUGHT TO CASUALTY WITH CIO SWELLING OF BOTH LOWER LIMBS SINCE 20 DAYS
CIO FACIAL PUFFINESS SINCE 20 DAYS
CIO SHORTNESS OF BREATH SINCE 4 DAYS
HOPI
PATIENT WAS APPARENTLY ASYMPTOMATIC 20 DAYS BACK THEN DEVELOPED SWELLING OF BOTH LOWER LIMBS INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE, PITTING TYPE C/O FACIAL PUFFINESS SINCE 20 DAYS
CIO SOB SINCE 4 DAYS INSIDIOUS IN ONSET GRADE 4NYHA GRADUALLY PROGRESSIVE
HIO ORTHOPNEA
HO CHEST PAIN FEVER, BURNING MICTURATION, ABDOMINAL DISTENSION NO H/O ABDOMINAL PAIN
NO H/O PALPITATIONS, DECREASED URINE OUTPUT PAST HISTORY:
KICIO HYPERTENTION SINCE 15 YRS ON TAB AMLODIPINE 5MG PO OD
DM II SINCE 10 YRS ON TAB GLlMI MI POOD
HIO TB 30 YRS BACK USED MEDICATION, COMPLETE COURSE NIKICIO ASTHMA, CVA, CAD, EPILEPSY PERSONALHISTORY:
DIET MIXED
SLEEP ADEQUATE
BOWEL AND BLADDER:STOOL NOT PASSED SINCE 3 DAYS, DECRESED URINE OUTPUT ADDICTIONS ALCOHOL SINCE 20 YRS STOPPED 3 MONTHS BACK APPETITE: DECREASED GENERAL EXAMINATION:
PATIENT IS CONSCIOUS COHERENT COOPERATIVE WELL ORIENTED TO TIME, PLACE AND PERSON
NO PALLOR, ICTERUS, CYANOSIS, CLUBING LYMPHADENOPATHY, EDEMA.
VITALS:
TEMPERATURE:98.6
BP:180/90 MM HG
PR: 64 BPM
RR.18 CPM
SYSTEMIC EXAMINATION
CVS.81,82 HEARD NO MURMURS.
RS.BAE + NO MURMURS
PER ABDOMEN SOFT,NON TENDER, NO ORGANOMEGALY CNS.NO FOCAL NEUROLOGICAL DEFICITS.
NEPHROLOGY REFERRAL DONE ON 21/ 1/24 LV/O INCREASED UREA AND CREATININE
ADVICE COLLAGEN PROFILE, URINE FOR BENCE ZONE PROTEIN, REVIEW WITH REPORTS,
DIAGNOSIS:
70 YR FEMALE/ 80 KGS
1. STAGE V CHRONIC KIDNEY DISEASE
NEPHROTIC SYNDROME SECONDARY Th ? DIABETIC NEPHROPATHY
PRENAL AMYLOIDOSIS
?MYELOMA KIDNEY|
HEART FAILURE WITH PRESERVED EJECTION FRACTION
HYPERTENSION/TYPE II DM
OLD PULMONARY KOCHS[30YRS AGO]
OPHTALMOLOGY REFERRAL DONE ON 22/1/24 IMO RETINOPATHY CHANGES DUE TO DIABETESIMPRESSIONINO EVIDENCE OF DIABETIC RETINOPATHYADVICE: STRICT
DIABETIC DIET, FUNDUS EXAMINATION FOR EVERY 6 MONTHS
COURSE IN THE HOSPITAL
PATIENT WAS BROUGHT WITH ABOVE MENTIONED COMPLAINTS ANDWAS DIAGNOSED AS DIABETIC NEPHROPATHY SYMPTOMATIC TREATMENT WAS GIVEN.THEN HYPONATRAEMIA OCCURED FOR WHICH 39 NACLINFUSION WAS STARED FOR WHICH NO IMPROVEMENT OBSERVED. NEPHROLOGY REFERRAL WAS DONE ADVISED INJ ALBUMIN 3
TRANSFUSIONS 2 ALBUMIN TRANSFUSIONS WERE DONE BUT NO IMPROVEMENT WAS THERE SO ADVISED FOR HEMO DIALYSIS BUT PATIENT ATTENDERS ARE NOT WILLING FOR HEMODIALYSIS AND WANT TO LEAVE AGAINST MEDICALADVICE
INVESTIGATION
RFT 17-01-2024 04:37.PM
UREA 78 mg/di 50-17 mg/di
CREATININE 4.0 mg/d 1.2-0.6 mg/di
URIC ACID 7.0 mg/ dl 6-26 mg/ dil
CALCIUM 9.7 mg/dl 10.2-8 6 mg/dl
PHOSPHOROUS 5.0 mg/di 4.5-2.5 mg/di
SODIUM 133 m€q/L 145-1 36 mEqiL.
POTASSIUM 3.6 mEq/L 5.1-3.5 mEd/L
CHLORIDE 94 m€q/L 98-107 mEq/L
LIVER FUNCTIONTEST (LFT) 17-01-2024 04 37.PM
Total Biturubin 0.65 mg/di 1-0 mg/di
Direct Bilurubin 0.19 mg/dl 0.2-0.0 mg/ dil
SGOT (AST) 15 IUIL 31-0 1UNL
SGPT(ALT) 10 IU/L 34-0 IU/L
ALKALINE PHOSPHATE 145 |U/L 141-53 JUL
TOTAL PROTEINS 4.9 qm/d 8.3-6.4 qm/di
ALBUMIN 2.7 qm/dl 4.6-3.2 gridi
AJG RATIO 1.20
COMPLETE URINE EXAMINATION (CUED$7-01-2024 04.37.PM
COLOUR Pale yellow
APPEARANCE Clear
REACTION Acidic
SP GRAVITY 1.010
ALBUMIN ++
SUGAR Nil
BILE SALTS Nil
BILE PIGMENTS Nil
PUS CELLS 3-6
EPITHELIAL CELLS 2-3
RED BLOOD CELLS NIl
CRYSTALS Nil
CASTS Nil
AMORPHOUS DEPOSITS Absent
OTHERS Nil
HB9Ag-RAPID 17-01-2024 04:37:PM Negative
Anti HCV Antibodies - RAPID 17-01-2024 04:37 PM Non Reactive
ABG 17-01-2024 04:54.PM
PH 7.31
PC02 29 8
PO2 73 4
HO03 14 8
St.HC03 16.4
BEB-9 g
BEect-10.2
T002 31.5
02 Sat 94 g
02 Count 12.7
T3, T4, TSH 17-01-2024
T30.36 ng/ mi 1.87-0.87 ng/ml
T47.83 micro g/di 12.23-6. 32 micro g/ di
T SH 1.94 micro lu/ml 5. 36-0.34 micro lumi
RET 18-01-2024 11 47.PM
UREA 86 mg/di 50-17 mg/di
CREATININE 3.7 mg/di 1.2-0.6 mg/di
URICACID 6.8 mo/d 6-26 mg/dl
CALCIUM 9.9 mo/ di 10.2-8.6 mg/di
PHOSPHORO US 4,9 mo/di 4.5-2.5 ma/di
SODIUM 135 mEc/L 145-136 mEd/L
POTASSIUM 3.7 mE¢/L5.1-3.5 mEg/L
CHLORIDE 98 mEq/L 98-107 mEgiL
RFT 19-01-2024 11:50:PM
UREA 89 mg/dI 50-17 maidi
UREA 89 mg/dI 50-17 mg/di
CREATININE 3.9 mg/dl 1 2-0.6 mo/ di
CREATININE 39 mg/di 1.2-0.6 mgidi
URICACID 6.6 mg/d 6-26 mg/dl
URICACID 6.6 mg/ di B-2.6 mg/ di
CALCIUM 8.0 mg/di 10.2-8.6 mg/di
CALCIUM 8.8 mg/di 10.2-8.6 mg/di
PHOSPHOROUS 5.1 mg/di 4.5-2.5 mg/di
PHOSPHOROUS 5.1 mg/dl 4.5-2.5 mg/di
SODIUM 120 mEq/L 145-1 36 mEqiL
SODIUM 130 mEq/L 145-1 36 mEq/L
POTASSIUM 3.2 mEq/L5.1-3.5 mE¢/L
POTASSIUM 2.6 mEq/L5.1-3.5 mEq/L
CHLORIDE 80 mEq/L 98-107 mEQ/L
CHLORIDE 94 m€q/L 98-107 mEq/L
RFT 20-01-2024
UREA 97 mq/dl
RFT 20-01-2024 11:51PM
UREA 97 mq/di 50-17 mg/dl
CREATININE 3.6 mq/d 1.2-0.6 mgidl
URICACID 6.0 mo/dl 6-2.6 mgid
CALCIUM 8.3 mg/ d 10.2-8.6 mg/di
PHOSPHOROUS 5.1 mg/dl 4.5-2.5 mg/dl
SODIUM 128 mE¢/L 145-136 mEd/L
POTASSIUM 3.6 mE¢/L5.1-3.5 mEq/L
CHLORIDE 96 mEq/L 98-107 mEq/L
SERUM ELECTROLYTES (Na, K, CD) AND SERUM IONIZED CALCIUM 21-01-2024 11:01:PM SODIUM 114 mEq/L 145-136 mEq/L POTASSIUM 3.8 mEq/L5.1-3.5 mEQ/L CHLORIDE 81 mEq/L 98-107 mEq/L CALCIUM IONIZED 1, 1 6 mmol/L immoliL
RFT 22-01-2024 12:22AM
UREA 109 mg/ di 50-17 mg/di
CREATININE 3.7 mq/di 1.2-0.6 maidi
URIC ACID 5.4 mg/dl 6-2.6 mgidl
CALCIUM 8.5 mo/ di 10.2-8.6 ma/di
PHOSPHOROUS 4.9 mg/dl 4.5-2.5 mg/dl
SODIUM 113 mEq/L 145-136 mEgiL
POTASSIUM 4.0 mE¢/L 5.1-3.5 mEdiL
CHLORIDE 84 mEq/L 98-107 mEgiL
SERUM ELECTROLYTES (Na, K, CU) AND SERUM IONIZED CALCIUM 20-01-2024 06:47 PM
SODIUM 113 mEQ/L 145-1 36 mEq/L
POTASSIUM 3.4 mEq/L 5.1-3.5 mEq/L
CHLORIDE 98 mEq/L 98-107 mEQ/L
CALCIUM IONIZED 1.23 mmol/L mmol/L
RFT 22-01-2024 11:09.PM UREA 96 mq/d1 50-17 ma/di
CREATININE 3.7 mg/dl 1.2-0.6 mg/dl
URIC ACID 5.0 mg/ dl 6-2.6 mg/ d CALCIUM 8.9 mg/di 10.2-8.6 mg/di
PHOSPHOROUS 4.8 mg/di 4.5-2.5 mg/dl
SODIUM 115 mEd/L 145-136 mEQ/L
POTASSIUM 4,0 mEq/L 5.1-3.5 mEg/L
CHLORIDE 99 mEq/L 98-107 mEq/L
SERUM ELECTROLYTES (Na, K, CI) AND SERUM IONIZED CALCIUM 2G-01-2024 05:37. PM SODIUM 113 mEq/L 145-136 mEq/L
POTASSIUM 3.9 mEqL5.1-3.5 mE¢L
CHLORIDE 79 mEq/L 98-107 mEgil
CALCIUM IONIZED 1.08 mmol/L mmoliL
RFT 23-01-2024 11 42 PM
UREA 104 mg/ d 50-17 mq/di
CREATININE 3.6 ma/d 1.2-0.6 mo/ di
URICACID 4.6 mg/ di 6-2.6 mg/ di
CALCIUM 10.0 mg/dl 1 0. 2-8.6 mo/di
PHOSPHOROUS 5.1 mg/di 4.5-2.5 mg/di
SODIUM 115 mE/L 145-136 mEq/L
POTASSIUM 3.2 mE¢/L5.1-3.5 mE/L
CHLORIDE 99 mEq/L 98-107 mEq/L
HAEMOGLOBIN 8.7gm/di
TOTAL COUNT 13,500cells/cumm
PCV 23.0 vol %M CV 77.7MM C H 29 4pgM C H C 37 8%RBC COUNT 2.96 millions/cumm
PLATELET COUNT2.92lakhs/cu.mm
LIPID PROFILE ON 18/1/24
Total Cholesteroll 44 my/diTrigily cerides137 mg/dIHDL Cholesterol# 33 mg/dILDL
Cholesterol79rre/di.VLDL27mg/d/24 HR CREATININE 26/DAY
24 HOURS URINARY PROTEIN4, 1 82mgiday 24 HOURS URINEVOLUME1.700ml.
HAEMOGLOBIN# 7.6gm/di
TOTAL COUNT 1 1, 30 0cells/cummPCV 19. 9vol 96M C V 76 STM C H 29.3рдм C H C 38. 295
HAEMOGLOBIN# 7.6gmidl
TOTALCOUNT 11, 300cells/cummPOV 19. 9v019M C V 76.81M C H 29. 3Ñ€ C H C 38.29
RBC COUNT# 2.59millions/curm3.8 - 4. 8Impedence
PLATELET COUNTS.5lakhs/cu.rrm1.5-4.1Impedence
SMEAR
HEMOGRAM
HAEMOGLOBIN# 5.7 qm/d/1 2.0 - 15.0Colorimetric
TOTAL COUNT# 10,600cells/ cumm4000 - 1 0000lmpedence
NEUTROPHILS76%40 - 80Light Microscopy
LYMPHOCYTES# 11%20 - 40Light Microscopy
EOSINOPHILS029601 - 06Light Microscopy
MONOCYTES# 11 %02 - 10Light Microscopy
BASOPHILS00%0 - 2Light Microscopy
2D ECHO ON17/01/2024
EF 60%
LEFT ATRIUM MID DILATED
LEFT VENTRICLE DILATED CONCENTRIC LVH, IC COLLAPSING(1 49 CMS]
MODERATE MR +, MODERATE AR+, MODERATE TR+ WITH MILD AH NO RWMA, NO AS/MS, SCLEROTIC AV
GOODLV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION + NO LV CLOT
REPEAT 2D ECHO ON 22/1/2024
NO RWMA, CONCENTRIC LVH, MODERATE TR+ WITH PAH MODERATE AR+, ECCENTRIC MR NO ASIMS, SCLEROTIC AV USG ABDOMEN
B/L GRADE I RPD CHANGES
LEFT SINGLE RENAL CORTICAL CYST
TREATMENT GIVEN
FLUID RESTRICTIONLESS THAN 1.5 LIT PER DAY
SALT RESTRICTION LESS THAN 2 GM PER DAY
INJ LASIX 40 MG IN BD
INJ PAN 40 MG IN OD INJ 3% NACL INFUSION
INJ MONOCEF 1GM IV ED X2DAYS
INJ ALBUMIN 20% INFUSION
TAB TELMISARTAN 40 MG PO OD
TAB NICARDIA 20 MG PO TID
TAB PRAZOPRESS XL 2.5 MG PO TID
1 HOUR AFTER TAB NICARDIA 20M (
TAB ZYTANIX 5MG PO OD
TAB SHELCAL CT PO OD
TAB PREGABALIN 75 MG PO HS
TAB SEVALAMER800MG PO TID
TAB ALDACTOME 50 MG OD
SYP ARISTOZYME 10 MLTID
SYP DULCOLAX 15 MLHS
NEPHRO PROTEIN POWDER 3 SCOOPS IN MILK WATER TID
3-4 EGG WHITES PER DAY
DIAGNOSIS
DIABETIC NEPHROPATHY
HYPOOSMOLAR HYPERVOLEMIC HYPONATREMIA
HYPERTENSION SINCE 15 YS
DIABETES MELLITUS SINCE 10 YRS
HO PULMONARY TB 30 YRS BACK
### Thematic Analysis of the Case
#### 1. **Coding:**
- **Chronic Conditions:** Stage V chronic kidney disease (CKD), nephrotic syndrome secondary to diabetic nephropathy, hypertension, type II diabetes, heart failure with preserved ejection fraction, old pulmonary tuberculosis.
- **Acute Symptoms:** Shortness of breath, bilateral lower limb swelling, facial puffiness, reduced urine output.
- **Imaging/Diagnostics:** Nephrology referral, ophthalmology for diabetic retinopathy, advice on fundus examination every six months.
#### 2. **Categorization:**
- **Renal Complications:** CKD progression, nephrotic syndrome likely from diabetic nephropathy.
- **Cardiac Involvement:** Heart failure with preserved ejection fraction.
- **Diabetes-Related Issues:** History of diabetes for 10 years, potential retinopathy.
- **Hospital Course:** Hyponatremia treated with saline infusion; failed response to albumin transfusion led to advice for hemodialysis, which was declined by family.
#### 3. **Theme Identification:**
- **Multisystem Disease in the Elderly:** Chronic diseases such as diabetes and hypertension leading to kidney failure and heart failure.
- **Refusal of Hemodialysis:** A significant decision impacting the prognosis, illustrating patient and family involvement in end-stage care choices.
- **Challenges in Management:** Complex case with multiple organ failure requiring multidisciplinary management, including nephrology, cardiology, and ophthalmology, complicated by treatment refusal.
#### 4. **Theme Representation (Learning Points):**
- **End-Stage CKD Management Challenges:** The patient’s case highlights the progression from chronic diabetes and hypertension to severe nephropathy requiring dialysis.
- **Patient Autonomy in Treatment Decisions:** The refusal of hemodialysis, despite the lack of improvement, reflects important aspects of patient and family decision-making in terminal illness care.
- **Complications of Long-Term Diabetes:** The case illustrates the development of nephrotic syndrome, potential amyloidosis, and retinopathy as long-term consequences of poorly managed diabetes.
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