48 yr old male with decreased urine output

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Case presentation:

A 48Y male, Church father by occupation resident of Nakrekal,presented with chief complaints of vomitings since 3 days

Patient was apparently asymptomatic 3 yrs back

In 2017 ,he had an injury to his left lower limb for which he was diagnosed as tendon rupture and he went to Orthopaedician and used PCM and pain killers for 2 months 

Later after few months he developed Burning micturation and easy fatigability for which he consulted doctor at Nalgonda and got to know that he had some kidney infection( patient language) and anemia for which he had taken Inj Iron Sucrose and he developed hyperpigmented itchy patches and took some ointment from Dermatologist. 

Later he consulted another doctor at Hyd where Rft was done got to know that his Serum Creatinine was increased(7 mg/dl) and they advised dialysis but he didnt get it done and came to our hospital and got Rft done where his Serum Creatinine was 4mg/dl and they told that no need of dialysis.

Later in 2018 He developed Shortness of breath when he was eating and he also had decreased urine output and came to our hospital and  got sr Creatinine done which was 18mg/dl then offered dialysis but they denied the treatment and left against medical advice. 10days later as his symptoms increased they came back then creat was 12 and undergone dialysis(4 in a month) and for next 9 months he was asymptomatic until August when he developed Shortness of breath and vomitings and 8 dailysis were done with 1 week apart and he developed Bilateral pedal edema after 7th dialysis and Shortness Of Breath since 1 week.

Then vomitings since 3days 3-4episodes / day food as contents immediately after intake, non projectile 

No h/o pain abdomen,loose stools

Past History

K/C/O Diabetes since 6 yrs and on Inj Insulin 2u morning and 2 units night ,Hypertension since 10 yrs and on Stamlo 5mg Od

K/C/O CKD since last november

N/K/C/O Asthma, CVA.

PERSONAL HISTORY:

Appetite lost

Mixed diet

Sleep adequate

Bowel movements regular

O/E

 Pt is conscious and cooperative moderately built and nourished. 

Bp 140/90 mmhg

Pr 99 bpm

Rr 22cpm

Temp 98°F 

Grbs 117 mg%

Pallor - absent

Icterus absent

Cyanosis - absent

Clubbing- absent

Lymphadenopathy - absent

Edema B/L pedal edema is present

Hyperpigmented patches 

Dermatology referral

CVS:

S1S2 heard, no murmurs

Respiratory system:

Bilateral air entry present

P/A - Soft and non tender,no organomegaly

CNS- Higher mental functions intact

Sensory and motor systems intact on both sides

All cranial nerves intact on both sides

Investigations:

2d echo

Ultrasound abdomen

Treatment:

Fluid restriction 

Salt restriction

Inj LASIX 40mg IV BD

Tab NICARDIA 10mg /PO/BD

Tab NODOSIS 500mg /PO/BD

Inj ERYTHROPOIETIN S/C weekly twice 

Inj HUMAN ACTRAPID INSULIN/SC/ Sliding scale 8am -2pm 8pm

Presently on Maintenance Hemodialysis 

DIAGNOSIS:

CHRONIC KIDNEY DISEASE ON MHD