Case 1 (Day 1: 22/12/2013)

Patient:

56 y/o Malay lady known case of hypertension, diabetes and End Stage Renal Failure presented with :

- progressively worsening shortness of breath 3/7 days
- bilateral lower limb swelling 3/7 days
- not compliant to fluid restriction

On Examination:

BP: 130/60 mmHg
Pulse: 80 beats/min regular volume and good strength
Respiratory rate: 22 breaths/min (tachypenic)
Temperature: 37.2 degree celcius (afebrile)

CVS: apex displaced (at 6 intercostal space). dual rhythm no murmur
Respiratory Examination: Bibasal crepitations.
Abdomen : Distended. soft non tender. (have not done fluid thrill & shiffing dullness as patient is uncomfortable)
Lower limbs: pitting edema up to the shin.

Provisional diagnosis: Fluid retention secondary to poor compliance to fluid restriction

In this patient on admission, i would like to order for the following:

1. Renal Profile and FBC
2. Arterial Blood Gas: Patient is breathless, has ESRF this maybe due to metabolic acidosis.
3. Chest X-ray
4. ECG: patient is breathless and has history DM and HT. she might be having atypical MI


Results:

Renal Profile: Urea (39.5) Creatinine (1282) sodium (131) potassium (5.1)

FBC: Hb (6.8); TWC (21.87; Neutrophilia); Platelet (503)

Chest x-ray: Cardiomegaly, bilateral blunting of costo and cardiophrenic angle

Cardiac enzyme: Normal

ECG: Atrial fibrilation


Plan:

1. IJC insertion for Haemodialysis
2. Start IV Frusemide 20mg stat then TDS
3. Nasal Prongs 3L oxygen per minute
4. continue other medications :
- T CaCO3 500mg TDS
- T Ferous fummarate 400 mg BD
- s/c actrapid 4 units if GM >10mmol/L

Patient went for haemodialysis.

<post haemodialysis>

Patient complains persistent breathlessness and lower limb swelling . Not improving despite having dialysis and frusemide.  

On examination: 

BP: 110/60

Respiratory rate:21 breaths/min 

Pulse: 86 beats;regular  

CVS: Dual rhytm no murmur 

Respiratory system: bilateral crepitations  

Abdomen: distended; soft non tender 

Lower limbs: pitting up to mid shin   

Ix: ECG review by MO: No AF only atrial ectopy 

Plan: 

Repeat renal profile (awaiting results) 

KIV transfuse one unit packed cells in view of low Hb 

Increase IV frusemide t0 40mg TDS

 post dialysis renal profile was as below:

Parameters	Values	Normal range
Urea	30.0  mmol/L	2.8-7.8 mmol/L
Sodium	131 mmol/L	135-145 mmol/L
Potassium	4.5 mmol/L	3.5-5.1 mmol/L
Creatinine	1020umol/L	61-124umol/L
Chloride	97	93-108 mmol/L
Phosphate	2.52	0.81-1.45 mmol/L
Corrected Calcium	2.23	2.20-2.65 mmol/L
Magnesium	1.04

Post haemodialysis renal profile showed a reduction in urea, potassium and creatinine levels.

She was transfused with one unit packed cells after the dialysis. 

Day 1 (24^th December 2013)

Patient still complains of breathlessness and lower limb edema. On examination, she was tachypenic, blood pressure 110/60mmHg, pulse rate: 80 beats/min with good volume and regular rate. On auscultation, there were bibasal crepitations audible. She was planned for a second haemodialysis to be scheduled on the 25^th of December in view of her raised urea levels and breathlessness. 

Day 2 (25^th December 2013)

Patient went for haemodialysis. Post dialysis renal profile is as below:

Parameters	Values	Normal range
Urea	20.0mmol/L	2.8-7.8 mmol/L
Sodium	133 mmol/L	135-145 mmol/L
Potassium	4.3 mmol/L	3.5-5.1 mmol/L
Creatinine	782umol/L	61-124umol/L
Chloride	96	93-108 mmol/L
Phosphate	2.45	0.81-1.45 mmol/L
Corrected Calcium	2.25	2.20-2.65 mmol/L
Magnesium	1.15

The renal profile shows a reduced level of urea and creatinine. Clinically patient is improving. Her breathlessness has improved. On examination, there are occasional bibasal crepitations and pitting edema up to the mid shin. 

Day 3 (26^th December 2013)

Patient feels that there is slight improvement in regards to her breathlessness as compared to yesterday. On examination, she was not tachypenic, blood pressure 112/58mmHg, pulse rate: 84 beats/min with good volume and regular rate.  There are occasional bibasal crepitations and pitting edema up to the mid shin.  She was scheduled for another haemodialysis the next day. A repeat FBC showed a Hb of 8.1 gd/L. She was planned for another unit of packed cell transfusion after her third dialysis.

Day 4 (27^th December 2013)

Patient feels breathless occasionally. On examination, she was not tachypenic, blood pressure 106/62mmHg, pulse rate: 80 beats/min with good volume and regular rate. there are occasional bibasal crepitations and pitting edema up to the mid shin.  She underwent her third haemodialysis and blood sample were taken for FBC and Renal Profile. She was scheduled to be discharge.

DISCHARGE PLAN, COUNSELLING AND MOCK PRESCRIPTION

Discharge Plan 

The final diagnosis by the hospital: Fluid retention secondary to fluid overload secondary to poor compliance to fluid restriction. 

Discharge plan was as follow:

1.    Advise patient on restriction of fluid <1L/day

2.    Patient to follow-up for dialysis at her own centre at Tanah Merah.

3.    Patient to come again in one month time for inspection of IJC and KIV change

4.    For infective screen at Tanah Merah  

5.    Discharge patient with:  

-       Tablet haematinics  

-       CaCO₃ 500mg TDS

-       Tablet frusemide 400mg OD

-       Tablet ranitide 150mg BD  

-       Anti-hypertensives were discontinued in view of good blood pressure control throughout hospital admission.