A 56 year old male with altered sensorium and CKD

A 56 Yr old male R/o Miryalaguda,  dialy labourer by occupation came to hospital on 19 November 2021 for his dialysis 

Hopi : 

Patient was apparently asymptomatic 2 years back when he was diagnosed with CKD when he had c/o bilateral pedal edema 

Patient has come to the hospital for his regular dialysis session on 19 Nov, after running regular tests he was told he requires blood transfusion. 

Dialysis session was delayed due to blood transfusion ( the last dialysis session was 14 days back). 

Patient developed fever since 3 days associated with chills and rigors and increased during night. No associated vomiting, diarrhea, shortness of breath. 

Patient's relative noticed slurring of speech and not responding to commands since 1 day 

Past history : 

H/o hypertension and diabetes mellitus since 4 years. 

Diagnosed with CKD 2 years back, for which he is on dialysis twice a week 

H/o blood transfusions 2 times in the past, recent one is 2 months back. And one more  blood transfusion on 24 th Nov 2021. 

Personal history : 

Diet - mixed 

Apetite - reduced 

Sleep - reduced 

Bowel - regular 

Bladder - reduced urine output since.... 

Addictions - consumes alcohol.Stopped 2 years back, no smoking history. 

Family history : 

No h/o kidney disease 

General examination : 

GCS - 10 

( opens eye spontaneously, no response to verbal command, withdraws limb on painful stimulus) 

Pallor - present 

Icterus - absent 

Cyanosis - absent 

Clubbing - absent 

Lymphadenopathy - absent 

Pedal edema - absent 

There are multiple purplish spots on his hand and leg ( purpura?) 

Vitals : 

Temperature - febrile

Pulse rate - 96 bpm 

Respiratory rate - 28 cpm 

Blood pressure - 140/90 mm of Hg

Systemic examination : 

CNS : 

Cranial nerve examination 

• Pupil dilated 
• Facial nerve is normal

Motor examination - 

• Bulk : no wasting of muscle 

           Mid arm circumference - 10 cm on left side

                                                          9. 5 cm on R side 

• Tone : upper and lower limb normal 
• Power : couldn't elicit 

Sensory examination

• Pain - flexes on painful stimulus 

Cerebellar signs - couldn't elicit 

Abdominal examination :

• Liver and spleen -no organomegaly
• Bowel sounds - present 

CVS examination : 

• S1 and S2 - heard
• Murmurs - not present 

Respiratory system : 

• Breath sounds - normal vesicular breath sounds

Investigations : 

Complete blood picture - 

Renal function test - 

Blood urea - 

Serum creatinine - 

 

Serum uric acid - 

Serum electrolytes - 

Doppler study - 2D echo

Diagnosis : Chronic kidney disease on MHD 

Treatment :

• Tab Lasix 40 mg  per oral BD 
• Tab pantop 40 mg per oral  OD 
• Tab Nicardia 20 mg per oral Tid 
• Tab Arkamine 0.1 mg per oral Tid 
• Tab Orofer TX per oral BD
• Tab Shelcal per oral OD 
• Tab Nodosis  500 mg per oral OD 
• Inj. Erythropoeitin 4000 I. U. once weekly