46 year old man with CKD on MHD

 A 46 year old man who was a sand blaster came to the hospital with complaints of loss of appetite since 3 months. Three months ago, he suddenly felt a decrease in his appetite and only ate one roti three times a day. Then one month ago, he had an episode of vomiting after eating mutton. It was food in content and non-bilious. Then, he went to his local hospital which told him he has a kidney problem and that he needs dialysis. Therefore, he underwent dialysis there then came to our hospital for dialysis due to financial problems. At our hospital, he was diagnosed with hypertension. 

General examination:

The patient was conscious, coherent, and cooperative, oriented to time, place, and person.

No history of pallor, icterus, cyanosis, clubbing, lymphadenopathy, and edema

No H/O nausea, fatigue, dehydration, constipation, decreased urine output, hematuria


Day 1

O/E:

BP: 150/90 mmHg

PR: 92 bpm 

CVS: S1S2 heard, no murmurs 

RS: BAE present

P/A: soft, non-tender

Rx: 1) Inj. Levipil 500 mg/IV/BD

       2) Inj. Pan 40 mg/IV/OD

       3) Inj. Lasix 40 mg/IV/BD

       4) Tab. Nicardia 20 mg /TID

       5) Fluid restriction <1.5 L/day

       6) Salt intake <2 g/day

       7) Tab. Nodosis 550 mg/ OD  

       8) Tab. Shelcal 500 mg/BD

       9) Tab. Orofer-XT /OD






Day 2

O/E: 

BP: 150/100 mmHg

PR: 60 bpm

CVS: S1S2 present, no murmurs heard

RS: BAE present

P/A: soft, non-tender

Rx: 1) Inj. Levipil 500 mg/IV/BD

       2) Inj. Pan 40 mg/IV/OD

       3) Inj. Lasix 40 mg/IV/BD

       4) Tab. Nicardia 20 mg /TID

       5) Fluid restriction <1.5 L/day

       6) Salt intake <2 g/day

       7) Tab. alpha-D3 0.25 mg/OD

       8) Tab. Nodosis 550 microgram BD PO

       9) Tab. Shelcal 500 mg/BD







Day 3

A case of CKD on MHD with k/c/o HTN with new onset Epilepsy. He complained of generalized body pains. 

O/E:

Afebrile

BP: 140/100 mmHg

PR: 78 bpm

CVS: S1S2 present

RS: BAE present

P/A: soft, non-tender

C/O generalized body pains

Rx: 1) Tab. Levipil 500 micrograms BD PO

       2) Inj. Pan 40 mg/IV/OD

       3) Inj. Lasix 40 mg/IV/BD

       4) Tab. Nicardia 20 mg /TID

       5) Fluid restriction <1.5 L/day

       6) Salt intake <2 g/day

       7) Tab. Nodosis 550 microgram BD PO

       8) Tab. Shelcal-HD OD PO







Day 4

No fresh complaints

Rx: 1) Tab. Levipil 500 micrograms BD PO

       2) Inj. Pan 40 mg/IV/OD

       3) Inj. Lasix 40 mg/IV/BD

       4) Tab. Nicardia 20 mg /TID

       5) Salt intake <2 g/day

       6) Tab. Nodosis 550 microgram BD PO

       7) Tab. Shelcal-HD OD PO   

       8) Tab. Clonazepam 0.25 mg PO

       9) Syp. Aristozyme 5ml TID PO ( 15 minutes before meals )




Day 5-7

No fresh complaints

Day 8

There is presence of central a line infection. There is a decrease of altered sensorium and fever spikes after giving Inj.Vancomycin 750 mg IV stat through central line and 1 session of HD.

O/E:

BP: 140/100 mmHg

PR: 87 bpm

CVS: S1S2 present

RS: BAE present

P/A: soft, non-tender

Rx: 1) Inj. Piptaz 2.25 mg IV TID

       2) Salt and water restriction 

       3) Inj. Pan 40 mg/IV/OD

       4) Tab. Shelcal-HD OD PO       

       5) Tab. Nodosis 550 microgram BD PO

       6) Tab. Levipil 500 micrograms BD PO




Day 9

He developed acute onset delirium secondary to septic encephalopathy due to central venous catheter infection. He had high grade fever spikes so the central line was removed. 

O/E:
Afebrile
CVS: S1S2 heard
RS: BAE present
P/A: soft, nontender

Rx:
1) Inj. Piptaz 2.25 g IV TID
2) Inj. Vancomycin 750 mg IV BD
3) Inj. Cefoperazone 750 mg IV BD with Sulbactam 3 g IV if available
4) Inj. Pantop 40 mg IV OD
5) Tab. Shelcal-HD OD PO
6) Tab. Nodosis 550 mg BD PO




Day 10

He still has fever spikes and on examination he is in an altered state of mind.

O/E:
BP: 160/110 mmHg
PR: 121/ min
CVS: S1S2 heard
RS: BAE present
P/A: soft, nontender
Pupils: 3 mm, sluggish but reacting to light

Rx:
1) Inj. Cefoperazone 750 mg and Sulbactam 0.5 mg/ IB/ BD
2) Inj. Pan 40 mg/IV/BD
3) Inj. Lasix 40 mg/IV/ BD
4) Tab. Nicardia 20 mg/TID
5) Fluid restriction < 1.5 L/ day and salt intake < 2 g/ day
6) Tab. Levipil 500 mg /BD
7) Tab. Nodosis 550 mg/ BD
8) Tab. Shelcal 500 mg/ BD
9) Inj. Neomol 1 gm/ IV Infusion
10) Tab. PCM 650 mg/ TID










Day 11

He is subjectively feeling better and had no fever spikes. 
Delirium secondary to uremic encephalopathy is resolved. 

O/E: 
Temp: 100 degrees F
BP: 160/100 mmHg
PR: 120 BPM
CVS: S1S2 heard, no murmurs
RS: BAE present
P/A: soft, nontender

Rx:
1) Inj. Cefoperazone 750 mg and Sulbactam 0.5 mg/ IB/ BD
2) Inj. Pan 40 mg/IV/BD
3) Inj. Lasix 40 mg/IV/ BD
4) Tab. Nicardia 20 mg/TID
5) Fluid restriction < 1.5 L/ day and salt intake < 2 g/ day
6) Tab. Levipil 500 mg /BD
7) Tab. Nodosis 550 mg/ BD
8) Tab. Shelcal 500 mg/ BD
9) Inj. Neomol 1 gm/ IV In











Day 12

He is complaining of loose watery stools (10 episodes) and dry cough. He had fever spikes in the morning. 

Rx:
1) Inj. Cefoperazone 750 mg and Sulbactam 0.5 mg/ IB/ BD
2) Inj. Pan 40 mg/IV/BD
3) Inj. Lasix 40 mg/IV/ BD
4) Tab. Nicardia 20 mg/TID
5) Fluid restriction < 1.5 L/ day and salt intake < 2 g/ day
6) Tab. Levipil 500 mg /BD
7) Tab. Nodosis 550 mg/ BD
8) Tab. Shelcal 500 mg/ BD
9) Inj. Neomol 1 gm/ IV In
10) Inj. Metrogyl 500ml in 100 ml IV/ TID
11) Tab. Alpha-D3 0.25 mg/OD
12) Tab. Solo 650 mg/ TID
13) ORS Sachets in 1 L water








Day 13

He passed stool 3 times during the night and no fever spikes

1) Inj. Cefoperazone 750 mg and Sulbactam 0.5 mg/ IB/ BD
2) Inj. Pan 40 mg/IV/BD
3) Inj. Lasix 40 mg/IV/ BD
4) Tab. Nicardia 20 mg/TID
5) Fluid restriction < 1.5 L/ day and salt intake < 2 g/ day
6) Tab. Levipil 500 mg /BD
7) Tab. Nodosis 550 mg/ BD
8) Tab. Shelcal 500 mg/ BD
9) Inj. Neomol 1 gm/ IV In
10) Inj. Metrogyl 500ml in 100 ml IV/ TID
11) Tab. Alpha-D3 0.25 mg/OD
12) Tab. Solo 650 mg/ TID
13) ORS Sachets in 1 L water







Day 14

He's been having dry cough overnight but no fever spikes. 

Rx: 
1) Inj. Cefoperazone 750 mg and Sulbactam 0.5 mg/ IB/ BD
2) Inj. Pan 40 mg/IV/BD
3) Inj. Lasix 40 mg/IV/ BD
4) Tab. Nicardia 20 mg/TID
5) Fluid restriction < 1.5 L/ day and salt intake < 2 g/ day
6) Tab. Levipil 500 mg /BD
7) Tab. Nodosis 550 mg/ BD
8) Tab. Shelcal 500 mg/ BD
9) Inj. Neomol 1 gm/ IV In
10) Inj. Metrogyl 500ml in 100 ml IV/ TID
11) Tab. Alpha-D3 0.25 mg/OD
12) Tab. Solo 650 mg/ TID
13) Syp. Grillinctus 10 ml/TID 








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