DIABETIC NEUROPATHY ON MHD

Case History and Clinical Findings 
C/O DECREASED URINE OUTPUT SINCE 4 MONTHS. 
HOPI-
 PATINT WAS APPARENTLY ASYMPTOMATIC 4 MONTHS BACK THEN DEVELOPED DECRESD URINE OUTPUT. 
PAST HISTORY
PATIENT IS A K/C/O DM TYPE-2 SINCE 10YEARS AND IS ON MEDICATION. 
N/K/C/O HTN, TB , ASTHMA, EPILEPSY , CVA, CAD, THYROID DISORDERS. 
GENERAL AND PHYSICAL EXAMINATION: PATIENT IS CONSCIOUS ,COHERENT,COOPERATIVE NO SIGNS OF PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY EDEMA+ 
VITALS: TEMP-97.4 F PR-84 BPM RR-18 CPM BP-100/70 MMHG SPO2-99% ON ROOM AIR CVS-S1 S2 HEARD,NO MURMURS 
RS-BAE+,NVBSCNS-NFND 
P/A- SOFT,NON TENDER,BOWEL SOUNDS HEARD
 Investigation
 CBP HB TC N L E M B PLT SMEAR RFT UR CR UA CA+2 P NA+ K+ CL- HIV HBSAG  BLOOD UREA12-09-2023  107 mg/dl SERUM CREATININE 6.9 mg/dlSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 12-09-2023 SODIUM 128 mEq/L POTASSIUM 3.4 mEq/L CHLORIDE 94 mEq/L CALCIUM IONIZED 1.27 mmol/LAnti HCV Antibodies - RAPID12-09-2023 11:22:AMNon Reactive HBsAg-RAPID12-09-2023 11:22:AM Negative COMPLETE BLOOD PICTURE (CBP) 12-09-2023 11:22:AM HAEMOGLOBIN 10.5 gm/dl TOTAL COUNT 18400 cells/cumm NEUTROPHILS 85 % LYMPHOCYTES 10 % EOSINOPHILS 01 % MONOCYTES04 % BASOPHILS 00 % PLATELET COUNT 3.96 SMEAR Normocytic normochromic Anemia with neutrophilic leucocytosis ABG 19-09-2023 01:36:AM PH 7.29 PCO2 31.6 PO2 41.3HCO3 9.2 St.HCO3 9.2 BEB-2.1 BEecf-2.4 TCO2 44.8 O2 Sat 79.3 O2 Count 9.2 RFT 19-09-2023 01:36:AM UREA 78 mg/dl CREATININE 5.3 mg/dl URIC ACID5.1 mg/dl CALCIUM 9.8 mg/dl PHOSPHOROUS 5.8 mg/dl SODIUM 138 mEq/L POTASSIUM 3.7 mEq/L CHLORIDE 100 mEq/L COMPLETE BLOOD PICTURE (CBP) 19-09-2023 01:36:AM HAEMOGLOBIN 12.2 gm/dl TOTAL COUNT 9100 cells/cumm NEUTROPHILS 81 % LYMPHOCYTES 09 % EOSINOPHILS 01 % MONOCYTES 09 % BASOPHILS 00 % PLATELET COUNT 2.29 SMEAR Normocytic normochromic ABG 19-09-2023 10:39:AM PH 7.49 Page-4 PCO232.3 PO2 75.8 HCO3 24.8 St.HCO3 26.2 BEB 2.0 BEecf 1.7 TCO2 52.2 O2 Sat 96.5 O2 Count 10.8 RFT 19-09-2023 10:39:AM UREA 83 mg/dl CREATININE 5.5 mg/dl URIC ACID 5.6 mg/dl CALCIUM 8.4 mg/dl PHOSPHOROUS 6.0 mg/dl SODIUM 137 mEq/L POTASSIUM 3.7 mEq/L CHLORIDE 99 mEq/LHEMOGRAM HAEMOGLOBIN 6.3 gm/dl TOTAL COUNT 11000 cells/cumm NEUTROPHILS 78 % LYMPHOCYTES12 % MONOCYTES 09 % BASOPHILS 00 % PLATELET COUNT 2.46 SMEAR Normocytic normochromic Anemia ABG 19-09-2023 07:34:PM PH 7.56 PCO2 28.7 PO2 154 HCO3 25.7 St.HCO3 28.0 BEB 4.0 BEecf 3.3TCO2 52.1 O2 Sat 98.6 O2 Count 14.1ABG 21-09-2023 05:58:AMPH7.49PCO224.9PO282.2HCO318.9St.HCO321.6BEB-3.4BEecf3.9TCO239.5O2 Sat96.7O2 Count11.4 ABG 22-09-2023 01:41:AM PH 7.44 PCO2 26.9 PCO2 269 HCO3 18.4 St.HCO3 20.2 BEB-5.0 BEecf-4.9 TCO2 40.6 O2 Sat 99.1 O2 Count 7.2RFT 22-09-2023 01:41:AMUREA107 mg/dlCREATININE4.5 mg/dlURIC ACID7.1 mg/dlCALCIUM7.6 mg/dlPHOSPHOROUS6.2 mg/dlSODIUM140 mEq/LPOTASSIUM4.2 mEq/LCHLORIDE102 mEq/L ABG 22-09-2023 05:00:PM PH7.44 PCO2 27.2 PO2 192 HCO3 18.2 St.HCO3 20.4 BEB-4.9 BEecf-5.2 TCO2 38.7 O2 Sat 98.6 O2 Count 11.0ABG 23-09-2023 12:41:AMPH7.42PCO231.9PO2206HCO320.7St.HCO322.0BEB-2.8BEecf3.0TCO244.8O2 Sat98.8O2 Count9.6 ABG 23-09-2023 01:27:AM PH 7.46 PCO2 31.0 PO2 113 HCO3 21.9 St.HCO3 23.4 BEB-1.2BEecf-1.4 O2 Sat 98.5 O2 Count 9.0 RFT 23-09-2023 01:27:AM UREA 141 mg/dl CREATININE 5.8 mg/dl URIC ACID 8.7 mg/dl CALCIUM 7.8 mg/dl PHOSPHOROUS 6.3 mg/dl SODIUM 139 mEq/L POTASSIUM 4.0 mEq/L CHLORIDE 101 mEq/L COMPLETE BLOOD PICTURE (CBP) 23-09-2023 01:27:AM HAEMOGLOBIN 5.6 gm/dl TOTAL COUNT 21000 cells/cumm NEUTROPHILS 85 % LYMPHOCYTES 11 % Page-9 ESINOPHILS00 % MONOCYTES 04 % BASOPHILS 00 % PLATELET COUNT 1.7SMEAR Normocytic normochromic Anemia with neutrophilic leucocytosis ABG 23-09-2023 03:09:PM PH 7.40 PCO2 36.4 PO2 76.9 HCO3 22.3 St.HCO3 23.0 BEB-1.6 BEecf-1.7 TCO2 48.1 O2 Sat 96.2 O2 Count 9.9ABG 23-09-2023 05:56:PMPH 7.41 PCO2 36.4PO2 94.4 HCO3 22.6 St.HCO3 23.4 BEB-1.2 BEecf-1.3 TCO2 47.6 O2 Sat 97.3 O2 Count 12.6 ABG 23-09-2023 10:31:PM PH 7.38 PCO239.0 PO275.3 HCO322.6 St.HCO322.9 BEB-1.8 BEecf-1.8 TCO247.7O2 Sat95.5 O2 Count12.2ABG 23-09-2023 11:24:PMPH 7.36 PCO2 41.1 PO2 271 HCO3 22.7 St.HCO3 22.8 BEB-2.0 BEecf-1.9 TCO2 49.6 O2 Sat 98.8 O2 Count 10.0 COMPLETE BLOOD PICTURE (CBP) 24-09-2023 04:47:AM HAEMOGLOBIN 6.3 gm/dl TOTAL COUNT22000 cells/cumm NEUTROPHILS83 % LYMPHOCYTES12 %EOSINOPHILS01 % MONOCYTES04 % BASOPHILS00 % PLATELET COUNT1.50 SMEARNormocytic normochromic anemia with neutrophilic leukocytosis .LIVER FUNCTION TEST (LFT) 24-09-2023 04:47:AMTotal Bilurubin 2.62 mg/dl SGOT(AST) 145 IU/L SGPT(ALT)ALKALINE PHOSPHATE 291 IU/L TOTAL PROTEINS 5.6 gm/dl ALBUMIN 1.62 gm/dl A/G RATIO 0.41 RFT 24-09-2023 04:47:AM UREA 135 mg/dl CREATININE5.1 mg/dl URIC ACID7.9 mg/dl CALCIUM8.7 mg/dl PHOSPHOROUS6.5 mg/dlSODIUM137 mEq/L POTASSIUM4.5 mEq/L CHLORIDE101 mEq/LABG 24-09-2023 11:06:AMPH 7.37 PCO2 37.4 PO2 126 HCO3 21.4 St.HCO3 22.0 BEB-2.9 BEecf-3.0 TCO2 46.1 O2 Sat 98.1 O2 Count 10.7 LIVER FUNCTION TEST (LFT) 25-09-2023 04:28:AM Total Bilurubin 1.63 mg/dl Direct Bilurubin1.09 mg/dl SGOT(AST)116 IU/L SGPT(ALT)7 IU/LALKALINE PHOSPHATE249 IU/L TOTAL PROTEINS5.4 gm/dl ALBUMIN1.5 gm/dl A/G RATIO0.41RFT 25-09-2023 04:28:AMUREA 161 mg/dl CREATININE 6.1 mg/dl URIC ACID 8.3 mg/dl CALCIUM 8.8 mg/dl PHOSPHOROUS 6.0 mg/dl SODIUM 137 mEq/L CHLORIDE 102 mEq/LCOMPLETE BLOOD PICTURE (CBP) 25-09-2023 04:28:AM HAEMOGLOBIN6.2 gm/dl TOTAL COUNT21200 cells/cumm NEUTROPHILS89 % LYMPHOCYTES07 % EOSINOPHILS01 %MONOCYTES03 % BASOPHILS00 % PLATELET COUNT1.5 SMEARNormocytic normochromic Anemia with neutrophilic leucocytosis
Diagnosis
 DIABETIC NEPHROPATHY ON MHD (? CKD ON MHD)
 Treatment Given-:
 1. FLUID RESTRICTION <15L/DAY 
2. SALT RESTRICTION <2GM/DAY 
3.INJ. NARADRENALINE (4ML+40ML NS)
 4. INJ. DOBUTAMINE (5ML +45ML NS) 5.INJ. VASOPRESSIN (1ML + 39ML NS)
 6. INJ. MIDAZOLAM 30 ML +INJ FENTANYL 4ML +16ML NS INFUSION @ 4ML +16 ML NS 7. IV. FLUIDS NS @30ML /HR 
8. INJ. LASIX 20 MG IV BD 
9. INJ. NEOMOL 1GM IV IF TEMP >101 F 
10. INJ. HUMAN ACTRAPID INSULIN ACC TO GRBS 
11. 7 PROFILE GRBS MONITORING 
12 RT FEEDS- WATER HOURLY, MILK 2ND HOURLY
 13. TAB. DOLO 650 MG RT/ BD SOS 
14. TAB. LINEZOLID 600MG RT/ BD
 15. MONITOR VITALS HOURLY
 16. INJ . MEROPENEM 500MG /IV/ BD
Death Summary 
A 71 YEAR OLD MALE PRESENTED WITH NON- HEALING ULCER OVER RIGHT LOWER LIMB TO CASULTY AND I/V/O RAISED RENAL PARAMETERS. DIALYSIS WAS INITIATED WITH DIAGNOSIS AKISECONDARY TO RIGHT LOWER LIMB CELLULITIS. SURGERY OPINION WAS TAKEN I/V/O CELLULITIS FOR WHICH DEBRIDEMENT WAS DONE INITIALLY AFTER 2 SESSIONS OF DIALYSIS . AND ON FURTHER EVALUATION BELOW KNEE AMPUTATION WAS PLANNED DUE TO ECTREME DESTRUCTION OF UNDERLYING TISSUE.AFTER 4 SESSIONS OF DIALYSIS RENAL PARAMETERS UREA AND CREATININE WERE REDUCED AND SURGERY WAS PLANNED FOR BELOW KNEE AMPUTATION AFTER GIVING HIGH RISK BY NEPHROLOGIST. AFTER SURGRY THERE WAS SUDDEN DECRESE IN URINARY OUTPUT (WHICH WAS NORMALPREVIOUSLY )AND FURTHER DIALYSIS WAS DONE . PATIENTS SENSORIUN DETERORATED GRADUALLY I/V/O FALL IN SATURATIONS AND HEARTRATE PATIENT WAS INTUBATED . DURING INTUBATION PATIENT HAD SUDDEN CARDIAC ARREST AND CPR WAS DONE ACCORDING TO LATEST ACCS GUIDELINES FOR A PERIOD OF 20MINS AND ROSC ACHIVED AND PATIENT PUT ON MECHANICALVENTILATOR IN ACMN -VE MODE. FURTHER GENERALSURGERY OPINION WAS TAKEN AND PLANNED FOR FURTHER DEBRIDEMENT OF WOUND BUT I/V/O PATIENTS PRESENT CONDITION IT WAS NOT DONE. PATIENT ALSO DEVELOPED HYPOTENSION SECONDARY TO SEPSIS AND WAS PUT ON IONOTROPIC SUPPORT AND 2 INJ. NORADRENALINE AND 2INJ. DOBUTAMIN AND 2INJ . VASOPRESSINE WITH ALL IONOTROPIC SUPPORT PATIENT WAS TAKEN UP FOR 1 SESSION DIALYSIS ALONG WITHBLOOD TRANSFUSION. PATIENT WAS HAVING PERSISTENT HYPOTENSION EVEN WITH IONOTROPIC SUPPORT AND ON 25/9/23 AT11 PM THERE WAS SUDDEN DROP IN SATURATIONS AND WITH PULSE AND BP NOT RECORDABLE, IMMEDIATELY CPR WAS INITIATED ACC TO LATEST AHA GUIDLINES BUT INSPITITE OF ALL RESUSCITATIVE EFFORTS PATIENT COULDN'T BE REVIVED AND DECLARED DEAD OM 25/9/23 AT 11:32PM IMMDEDIATED CAUSE OF DEATH - REFRACTORY HYPOTENSION WITH TYPE -1 RESPIRATORY FAILURE.ANTECEDENTCAUSE- CHRONIC KIDNEY DISEASE WITH S/P RIGHT BELOW KNEE AMPUTATION SECONDARY TO RIGHT LOWER LIMB CELLULITIS WITH K/C/O DM TYPE-2

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