DAYS IN NEPHROLOGY

My day started on 9th May 2020 with Morning rounds of my patients in Nephrology ward with my intern.

At around 11am , A Patient presented to the casualty, A 60 year old man, Farmer from a local village, Occasional Alcoholic since 25 years and Chronic Beedi Smoker since 25 years, who was diagnosed to be hypertensive and diabetic 6 months back. 

He apparently had no medical issues until an year back when he started getting breathless on walking for a few miles and he gradually started experiencing breathlessness even on rest, on & off though he had no complains of associated chest pain, palpitations, nausea, vomitings or associated giddiness.

One fine morning, before he started for work he observed his feet were swollen upto his ankles for which he decided not to consult a doctor and managed by resting for a few days. Over the next few days the swelling in his feet gradually progressed up to his thighs and it alarmed him when he had developed facial puffiness. He also started to notice that his urine was frothy. He immediately rushed to a local hospital where he was told that his kidneys were injured and was started on certain drugs.

On reviewing his old reports, his Serum Creatinine was 6mg/dl with a Blood Urea of 135 mg/dl with a significant proteinuria of 3 g/day. He was put on Torsemide, Sodium Bicarbonate, Calcium. After 6 months he was also told that he was hypertensive and diabetic. 

When he presented to our hospital, he was breathless Grade 4 and complained of reduced urine output since 1 day. 

He was cachexic, thin built, pale, no cyanosis or clubbing.

Jvp was not raised.

 He had Right eye Cataract

He was in Respiratory distress with a respiratory rate of 28 cpm, Saturations maintaining at 95 % at Room air.

Blood pressure was 110/70mmhg with a pulse rate of 100bpm.
On examination,
Patient had a barrel shaped chest with an everted umbilicus.
Respiratory distress was present with indrawing of intercostal spaces.
Percussion of the lung fields were resonant and on auscultation the lungs were clear.
His apex beat was present in the 5th intercostal space 1cm lateral to the midclavicular line.
S1 and S2 could be auscultated.

, 

His ABG showed a pH of 7.02, pC02 -30, pO2 - 70, Hco3 - 10 showing metabolic acidosis with compensatory respiratory alkalosis. Sr Creatinine was 18 mg/dl, Blood Urea was 18 mg/dl,  Serum Potassium was 4.3 mEq/L. His Hb was 7.3g.dl, TLC - 4800 cells/cumm, Platelet count - 1.57 L/cumm.

Chest X Ray PA showed tubular heart, wide spaced inter costal space, flattened diaphragms, increased broncho vascular markings - ? COPD changes

2DECHO revealed concentric Left ventricle with a good Ejection Fraction and collapsing IVC

 

DIAGNOSIS : Metabolic acidosis with Compensatory Respiratory Alkalosis

 Chronic kidney disease ( Risk factors being Hypertension, Type 2 DM, Alcohol and Tobacco consumption)

? COPD

HTN & TYPE 2 DM 

Sodium Bicarbonate - 100 mEq/ IV stat was given over 5 minutes.

Placed a Central line through his Internal Jugular Vein and shifted him for Hemodialysis.

By 4pm, another Elderly man, 70 years old presented to Casualty, who was already a known case of Chronic Kidney Disease since 15 years on  maintenance hemodialysis, known case of hypertension since 25 years, he presented with dyspnea with a Respiratory rate of 30 cpm, Blood pressure was at 60 mmhg systolic and heart rate of 100 bpm, saturations at 80 %

His lungs were clear

Heart sounds - S1,S2 heard

Ecg showed no significant changes

Put the patient on Oxygen supplementation

and Gave a bolus infusion of Normal Saline through IV route.

The patient was started on Noradrenaline -  8mcg/min IV infusion.

The attendants weren't willing to stay inspite of explaining the need to stay in the hospital, the patient left against medical advice after the patient was stabilized.

Had a 2-4 pm theory class, learnt a few points regarding Pheochromocytoma also known as the Great Masquerader because of the variable clinical presentation the patients present with. 

I also learnt that Pheochromocytoma could be associated with Cushing's syndrome. 

Cushing's syndrome could be ACTH dependent, ACTH independent or due to exogenous use of glucocorticoids. Here is a case report i found regarding a woman with Subclinical Cushing's syndrome due to ACTH secreting pheochromocytoma.

A 53 year old woman who presented with recurrent attacks of hypoglycemia, hypokalemia, metabolic alkalosis, labile hypertension with an incidental ultrasonography revealing right adrenal mass. Subclinical Cushing's syndrome was detected in her following low dose dexametasone suppression test of 188.7 ug/dl, Serum ACTH OF 375 pg/ml indicating ACTH dependant Cushing's syndrome. high levels of 24 hours urinary metanephrine ((3737 ug/g) & 24 hours urinary normetanephrine (1169 ug/g).

http://www.cjhr.org/article.asp?issn=2348-3334;year=2016;volume=3;issue=4;spage=291;epage=294;aulast=Chanukya

Theory :

Studied about Brain stem strokes with two of my colleagues. 

Mentioned few points which i learnt here

https://ashiness92.blogspot.com/2020/05/brain-stem-strokes.html

Thesis :

Will be updating about my thesis on my page soon.