SUBJECTIVE EVIDENCE

• Patient came for regular check up and found that there was feeble and
fast heart rate so referred to emergency.
• 1 episode of loose stools 3 days back and decrease in appetite.
• Decreased urine output, vomiting.

Past Medical History

• HTN * 10 years
• CKD * 3 years

Past medication history

• Tab. Amlodipine 5 mg PO 1-0-0
• Cap. EIDO 1-0-1
 OBJECTIVE EVIDENCE
• Vitals
Vitals D1 D2 D3 D4 D5 D6 D7

Temp(F) 98.6 97 98 98.4 97.6 98.2 97.8

RR(cpm) 28 25 22 22 20 20 20

HR(bpm) 175 100 120 110 96 98 82

BP(mmHg) 140/100 70/68 85/80 130/70 110/80 110/70 110/80

• Pallor +
• CVS-irregular heart sounds, no murmurs.
 Lab data
TEST TEST VALUE NORMAL VALUE
Urine analysis
Specific gravity 1.015 1.016-1.022
Appearance Slightly turbid Clear
Protein 2+ Negative
WBC/pus cells 6-8 0-3/hpf
RBC 1-2 Absent

BUN 51 mg/dl 8-20

Total protein 5.8 g/dl 6.4-8.3
Sr.Albumin 3.1 g/dl 3.4-5.0
Globulin 2.7 g/dl 2.0-3.1
A/G ratio 1.15 1.2-1.7
ALT 37 U/L 7-56
ALP 186 IU/L 44-147
APTT 47.7 sec 23.7-30.8
PT 22.8 sec 10.3-13.2
Hgb 9.9 g/dl 12.0-15.0
RBC 3.2 m/cmm 3.85-5.16
PCV 29% 34.8-45.0
RDWCV 15.5% 11.3-14.7
Basophils 00% 0.0-2.0

Sr.creatinine 3.2 mg/dl 0.6-1.1

Sr.sodium 119 mmol/L 136-145
Sr.potassium 2.5 3.5-5mEq/L
pH 7.30 7.34-7.45
pCO2 16.0 mmHg 38-42
pO2 98 mmHg 75-100

GFR= 15.58 ml/min

 OTHER DIAGNOSTIC TESTS
ECG on day 1
• Atrial fibrillation with fast ventricular rate

ULTRASOUND SCAN OF ABDOMEN AND PELVIS

• Bilateral grade 4 renal parenchymal disease + cystitis.
 ASSESSMENT
From the subjective and objective evidence it was assessed that the patient
was suffering from
• chronic kidney disease(Sr. creatinine , BUN, Decreased urine output,GFR-
15.5ml/min) etc)
• UTI(Presence of WBC in urine, US-Cystitis)
• Anemia of CKD( Decreased level of Hb, RBC, PCV)
• Hypertension
• Atrial fibrillation(ECG.)
 PLANNING

• GOALS OF THERAPY
Short term :To treat acidosis
To regulate the heart rate.
To treat UTI.

Long term : To prevent the further progression of disease.

To prevent further complications.
To improve the quality of life.
 STAT MEDICATIONS
BRAND GENERIC DOSE ROUTE FRQNCY

Inj.Metoprolol Metoprolol 5mg IV stat

Inj.Emeset Ondansetron 2mg IV stat

Heparin Heparin 5000u IV stat

Inj.Cordarone Amiodarone 150mg IV In 5%D,100ml
over 1hr

Inj.Dopamine Dopamine 5mcg/kg/min IV Stat

Inj.Noradrenalin Noradrenaline 0.05mcg/kg/mi IV stat

e n

KCl+NS KCl+NS 40mEq IV infusion

 TREATMENT GIVEN
BRAND NAME GENERIC NAME DOSE ROA Freq

Inj.Meropenem Meropenem 0.5 g iv Q12h

Syp.KCl KCl 15 ml po Q12h

50% dextrose dextrose 500 ml iv OD

T.Acitrom Acenocoumarol 1mg po OD

T.Diltazem Diltazem 30mg PO Q12h

Syp.Lactulose Lactulose 30 ml po HS

INJ.Magnex forte Cefoperazone+sulbactum 1.5gm iv BD

Tab.Pan pantoprazole 40mg po OD

 DISCHARGE TREATMENT
BRAND GENERIC NAME DOSE ROUTE Freq DURATION
NAME
T.Acitrom acenocoumerol 1mg Po 1-0-0 * 1week

40mg Po 1-0-0 *1 week

T.Pan pantoprazole (before food)

T.diltazem diltiazem 30mg Po Q12hr *1 week

Cap.nephroc multivitamin 100mg Po 0-1-0 *1 week

aps

Inj.EPO erythropoietin 4000 sc Weekly once *1 week

units
 MONITORING PARAMETERS
DRUG SPECIFIC DISEASE SPECIFIC
• RFT , LFT • RFT
• BP • Hematology
• Heart rate • Urine analysis
• ECG • Urine and blood cultures
• Haemotocrit
• ECG,ECHO
• Urine output
• Ultrasound scan of abdomen
and pelvis
Problems identified
• Fluid Input / Output ratio
• ADR- Amiodarone induced
hypotension.
• Anemia was not treated during
hospitalization
 PATIENT COUNSELLING
DISEASE SPECIFIC:
• Chronic kidney disease, also called chronic renal insufficiency
or progressive kidney disease by some, is defined as a
progressive loss of function occurring over several months to
years, and is characterized by the gradual replacement of
normal kidney architecture with interstitial fibrosis.
• General symptoms associated with stages 1 to 4 include
edema, cold intolerance, shortness of breath, palpitations,
cramping and muscle pain, depression, anxiety, fatigue, and
sexual dysfunction.
• Atrial fibrillation is the irregular or rapid heart beat
• Anemia is nothing but a lack of RBC in the blood
• UTI is the infection of the urinary tract due to micro-organisms
• Drug specific :

• T.pan should be taken half an hour before food.

• Take pantoprazole for the full prescribed length of time. Your symptoms
may improve before the condition is fully treated.

• Excessive consumption of Grapefruit may interact with diltiazem by

increasing its effect and lead to potentially dangerous effects.

• Inj Erythropoietin should be taken subcutaneously once in a week.

Regularly check BP .If there is occurrence of any seizures stop the
medication and report to the doctor

• Do not skip the dose

Lifestyle modifications :

• Don’t use public toilets

• Always practice good hygiene
• Clean the genital and urinary areas with soap and water after each bowel
movement
• Avoid tight-fitting pants
• Wear cotton panty's and should change at least once a day.
• Take showers rather than bath
• Empty your bladder as soon as you feel the urge to urinate ,don’t hold back
• Take garlic more which increase immunity power to fight against infections
• Reduce your salt intake
• Include iron rich food like spinach, liver, beans, apricot, raisins, peas.
• As you have hypertension try to avoid stress
• Regular follow up should be there
• Take medication regularly
• Don’t take any OTC medication
• Get regular aerobic exercise (such as walking at least 30 minutes a
day, several days a week)
• Do meditation regularly