50year male with uremic encephalopathy
A 50 year old male came to the opd with chief complaints of
Decreased urine output since 15 days
Loss of appetite since 1 week
Shortness of breath, facial puffiness, nausea and vomiting since 15 days.
HOPI :
The patient was apparently symptomatic 2 years ago when he developed low back ache along with pain in the knee joints, elbow and wrist joints for which they went to the local hospital and took analgesics and got relieved. Patient was normal for 1-2 weeks. Then again started developing multiple joint pains along with low back ache for which he used to go to local pharmacy and took some analgesics on and off for about 2 years.
Inspite of not getting symptomatic relief, he developed decreased urine output along with vomitings which were non bilious and non projectile since 15 days for which he consulted the doctor where he was told the kidneys were affected and referred here for further evaluation on 8-06-21.
On 8-06-21 :
Urine albumin is 3+
Serum creatinine 16.6 mg/dl (.9-1.3)
Blood urea 214 mg/dl (12-42)
Hb 7.14 g/dl
On 9-06-21 :
Usg showed b/l grade 2 CKD changes.
He was diagnosed with
CKD secondary to NSAID induced nephropathy.
On day 1:
Hemodialysis done.
T. Nicardia 10mg BD
T. Lasix 40mg BD
T. Orofer XT BD
INJ. Erythropoietin 4000 IU
T. Nodosis 550 ng BD
T. Shelcal 500 ng OD
On day 2:
On further questioning the patient further he complained of itching all over the body.
Added
T. Citrizine 5mg
On day 4 another dialysis was done.
On day 5,
He had 2 episodes of involuntary movements of right upper and lower limbs (clonic type) not associated with micturition or defecation associated with tongue bite.
On examination after the episode,
Pt is irritable, not oriented to time,place and person.
BP 140/80mm hg
PR 108 bpm
CNS EXAMINATION :
Tone :
B/l - UL 2+ LL 2+
Power :
UL r 2+ l 3+
LL r 2+ l 3+
Couldn’t elicit reflexes.
Probable diagnosis : Uremic encephalopathy
Treatment :
Added :
INJ. Levipil 1g in 100ml NS IV
Levipil 500mg IV BD
On day 6,
The patient was irritable and oriented to person but not time and place.
On day 8 dialysed.
On day 9,
He was consious and oriented to place and person.
He had a fever spike on 17-06-2021 at 6:00 pm for which he was given paracetamol and it subsided.
On 19_6_ 2021
Dialysed
On 20-6-2021
1)IVF NS 0.9%
2). Inj. Monocef 1gm/IV/BD
3) Inj. Lasic 500mg/PO/OD
4)T. Levipil 500mg /PO/OD
5) T. Nodosis 550mg/PO/BD
6) T.Orofer -XT /PO/OD
7) T.Shelcal PO/OD
8) T. Metrogyl 500mg/PO/BD
9)ORS sachet in 1 lt of water /PO/ whole day.
On 21-6-2021,
1)IVF NS 0.9%
2). Inj. Monocef 1gm/IV/BD
3) Inj. Lasic 500mg/PO/OD
4)T. Levipil 500mg /PO/OD
5) T. Nodosis 550mg/PO/BD
6) T.Orofer -XT /PO/OD
7) T.Shelcal PO/OD
8) T. Metrogyl 500mg/PO/BD
9)ORS sachet in 1 lt of water /PO/ whole day.
Final diagnosis:
New onset seizure secondary to uremia (resolved).CKD secondary to NSAID induced nephropathy asssociated with pruritis secondary to uremia. Uremic encephalopathy.
On 22/6/2021:
At 8.00 am
Pt. was C,C,C
BP 130/70 mmHg
PR 94 BPM
CVS S1, S2 heard, no murmurs
Resp. NVRS +, no added sounds
GRBS 90 mg/dl
1)IVF NS 0.9%
2). Inj. Monocef 1gm/IV/BD
3) Inj. Lasic 500mg/PO/OD
4)T. Levipil 500mg /PO/OD
5) T. Nodosis 550mg/PO/BD
6) T.Orofer -XT /PO/OD
7) T.Shelcal PO/OD
8) T. Metrogyl 500mg/PO/BD
9)ORS sachet in 1 lt of water /PO/ whole day.
10) Tab. NicardiaNicardia 10 mg PO/ BD
11) Tab. PCM 500 mg PO SOS
At 11.40 am:
PATIENT HAS BEEN OBSERVED WITH FAULTY BLOOD PRESSURE & SATURATION ,CPR WAS INITIATED AND CONTINUED FOR 10 CYCLES .PATIENT WAS ADMITTED ON 18/06/2021 AT 4:40 PM HAD SHORTNESS OF BREATH ( GRADE 3 - GRADE 4 ) HAD UREA ELEVATED
PT HAD SEIZURES IN BETWEEN AS EPISODES HAD UNDERGONE 2 DIALYSIS ( HEMODIALYSIS) ON 22/06/2021 11: 40 AM PATIENT WAS OBSEVED WITH FALLING BP AND SATURATION CPR INITIATED AND GIVEN ROUNDS OF CPR
CPR notes:.
TIME. BP, PR. INJ. GIVEN
At 11:45am : NR. Adrenaline 1g
11:50am:. NR. Adrenaline 1g
11:55am:. NR. Adrenaline 1g
12:00pm: NR. Adrenaline 1g
12:10 pm: NR. Adrenaline 1g
DESPITE ON EFFORTS PATIENT COULDNT BE REVIVED AND DECLARED DEATH ON 22/ 06/ 2021 AT 12 : 17 PM
IMMEDIATE CAUSE OF DEATH:
SUDDEN CARDIO PULMONARY ARREST
ANTECEDENT CAUSE OF DEATH :
NEW ONSET SEIZURES SECONDARY TO UREMIA ( RESOLVED) WITH CKD SECONDARY TO NSAID INDUCED NEPHROPATHY WITH UREMIC ENCEPHALOPATHY
