A case of 65 year old male with decrease in urine output and shortness of breath

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT."

A 65 year old male came to the OPD with the chief complaints of decrease in urine output since 1 week,  bilateral Lower limb swelling since 1 week and difficulty in breathing since 3 days , stoppage of urine output since 2 days.

Patient was apparently asymptomatic 1 week back then he  developed decrease in urine output since 1 week and then complete stoppage since 2 days , pedal edema since 1 week , shortness of breath since 3 days which is grade 2 .

 There is a history of bullous lesion on the dorsum of right hand . 

He also had jerky movements of upper and lower limbs  which are asymmetric, arrhythmic and bilateral . 

Past history- patient had a similar history 2 years back which is decrease in the urine output and pedal edema and there was a history of 3 dialysis sessions in 2020 followed by medical management . There was also a history of COPD since 3 years . And there is a history of hypertension and neck pain since 10 years . 

Personal history - patient takes mixed diet , appetite is normal , sleep is adequate , bowel movements are regular , there is decrease in the urine output . He consumes alcohol occassionally.

General examination- 

Patient is conscious , not coherent and not co-operative , not oriented to time , place and person .

He looks pale , no icterus , no cynosis , no clubbing , no lymphadenopathy , there is bilateral pitting edema in the foot 

Vitals - 

Temp - afebrile 

BP- 90/60 mm hg on ionotropes

PR - 80bpm 

RR - 16 cycles / min 

SpO2 - 98 %

Systemic examination-

CVS - S1 , S2 are heard  , no murmers 

Resp system - normal vesicular breath sounds heard , there is dyspnea 

Per abdomen - 

On inspection- abdomen is distended, flanks are full , umbilicus is slit shaped 

On palpation - no tenderness , 

Liver , spleen - not tender, not palpable 

On percussion- dullness is heard 2cm lateral to umbilicus 

Auscultation - bowel sounds are heard

CNS - patient not responding to simple commands

B/L pupils NSRL

All limbs are moving against gravity

E2V1M4 

Investigations - 

2D echo shows right atrium and right ventricle dilation , inferior venacava dilation with severe tricuspid regurgitation

As of 28 Jan 2022 , 

Urea = 193 mg/dL -> 152 mg/dL -> 176 mg /dL  -> 168mg/dL ->110 mg/dL -> 76 mg/dL

 creatinine = 7.4 mg/dL -> 6.3 mg/dL->6.9mg/dL->6.8mg/dL->5.0mg/dL->3.5mg/dL

Hb =10.2 -> 6.6 -> 8.0 -> 7.4 -> 6.9 

TLC - 17000 -> 20400 -> 41180 -> 26300 -> 12600 

Platelets - 1.91 lakhs -> 1.5 -> 1.6 -> 1.2 -> 1.0 lakhs 

Provisional diagnosis - 

Chronic kidney disease with COPD

Treatment- 

Inj . lasix 20mg IV BD 

Inj. NORAD 20ml / hr

Inj. DOBUTAMINE 7.2 ml/hr 

IV fluids NS @uo+ 50ml/hr

Nebulization with Ipravent and budecort

Inj . Optineuron 1amp in 100ml NS IV OD

Tab. Pulmoclear 100mg po BD 

Tab. Orofer XT po BD