MEDICINE BIWEEKLY BLENDED ASSESSMENT

1) What is your complete anatomic and etiologic diagnosis from the data available in the patient's online record linked above? (ignore the provisional diagnosis on admission mentioned in the case report) 

The 45 year old female patient came to the opd with the chief complaints of swelling in legs which progressed to become abdominal as well as facial puffieness which was associated with decreased urine output since 5 days

Looking at the history of the patient, she has been diagnosed with type 2 diabetes 5 years ago and also with hypertension one year ago. 

Anatomical diagnosis 

Observing the symptoms we can conclude that the problem is with these systems  

Renal - decreased urine output, edema

Cardiovascular - hypertension (shortness of breath)  

Etiological diagnosis 

Keeping in mind that she is a known diabetic and hypertensive patient 

We can try to understand the aetiology behind the loss of function at the above mentioned anatomical sites/systems 

Renal - here the reasons for reduced urine output may be from a simple blockage in the urinary tract, damage to the kidneys, infection of the kidneys and many more possibilities  

BUT when we add the known facts of our patient to the picture it narrows down the possibilities to kidney damage due to hypertension (less likely due to less duration) or diabetes (more likely due to longer duration)

The general oedema may be due to this loss of kidney function. 

Cardiovascular - patient is a known case of hypertension and diabetes 

Hypertension might have lead to hypertrophic cardiomyopathy which is aggravated by the decreased urine output leading to shortness of breath of a considerable degree which in turn has lead to respiratory acidosis.

 

2) What are the reasons for her: 

Azotemia  

Refers to the elevated levels of urea and nitrogen in her blood 

This in this case is due to the injury to her kidneys becasue of diabetes 

Anemia 

Tied up with her kidney injury 

As erythropoietin an important erythrocyte regulating protein is secreted by the kidney  

Hypoalbuminemia  

Is decreased albumin levels in blood 

This may be due to certain underlying heart conditions (congestive heart failure) *** relation unclear 

Acidosis  

Increased pH of the blood is called acidosis 

The shortness of breath leads to decreased expulsion of carbon dioxide causing acidosis of blood 

Respiratory acidosis 

 

3) What was the rationale for her treatment plan detailed day wise in the record? 

 

Day 1 

The pressing things noted are her acidosis, hypokalemia, and high blood pressure accordingly 

Treatment given - 

1.inj.NaHCO3 100 meq/iv/stat in 100 ml NS - to correct the acidosis 

2.syp.POTCHOLR  15 ml in one glass water TID - the syrup contains KCl used to correct hypokalemia

3.anti hypertensives - to control her blood pressure (180/80 mm Hg)

 

Day 2

Treatment - 

1.inj.HAI  according to sliding scale - to treat her diabetes

2.t.OROFER xt bd - to deal with anemia

3.t.PAN 40 mg od

4.inj.LASIX 40 mg iv bd if systolic bp >110mmhg - furosemide to reduce the oedema and the load on heart and also to help with shortness of breath 

 

Day 3 and 4

Treatment - 

1.inj.lasix 40mg iv bd - shortness of breath and edema 

2.tab.dytor 20mg of po - also a diuretic 

3.inj.HAI S/C according to sliding scale - diabetes 

4.tab.telma 40 mg od po->tab.nicardia 10 mg po/sos - hypertension

Stopped telma

5.tab.orofer ct bd po - for the anemia 

6.inj.erythropoietin s/c twice weekly - for managing anemia 

7.tab.nodosis 500 mg bd po - sodium bicarbonate for acidosis

8.tab.shelcal ct po/op - for hypocalcemia 

9.syp.potcholr 15ml in one glass water tid - for hypokalemia 

 

Day 5 

Treatment added -

1.Syp.lactulose 30ml bd 

2.protein x powder 2tbsp in one glass milk bd - to restore oncotic pressure

3.inj.MONOCEF 1gm IV bd - antibiotics

 

Indications for oral bicarbonate 

indigestion 

excess pH of urine 

acidosis 

 

Indications for iv bicarbonate 

Indicated in the treatment of metabolic acidosis 

(which can occur in severe renal disease, uncontrolled diabetes, circulatory insufficiency due to shock, anoxia or severe dehydration)

 

Contraindications of bicarbonate

it causes salt retention therefore it is contraindicated in renal failure, respiratory or metabolic alkalosis, hypernatremia, hypertension, congestive heart failure.

4) What was the indication for dialysing her and what was the crucial factor that led to the decision to dialyze her on the third day of admission? 

 

indications for dialysing her were  

her high BUN and azotemia
severe fluid overload

emergency dialysis on the third day was the severe shortness of blood leading to acidosis which has to be managed immediately to save patient from electrolyte imbalance complications

 

5) What are the other factors other than diabetes and hypertension that led to her current condition? 

6) What are the expected outcomes in this patient? 

7) How and when would you evaluate her further for cardio renal HFpEF and what are the mechanisms of HFpEF in diabetic renal failure patients?

8) What are the efficacies over placebo for the available therapeutic options being provided to her for her anemia

9) What is the contribution of protein energy malnutrition to her severe hypoalbuminemia? What is the utility of tools such as SGA subjective global assessment in the evaluation of malnutrition in CRF patients?