Case of 60 yr old Female with ? CHRONIC RENAL FAILURE due to ?protein powder consumption ?gouty arthritis ? Diabetic nephropathy causing ?CRF

 30th March ,2022 

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box"

A 60 year old tubectomized (22yrs -ago) female homemaker , from miryalaguda came to us yesterday morning with the 

C/O 

Unable to walk since 4 days 

Unable to work since 4 days 

Swelling of hands and feet since 5 days 

Swelling of the face since 5 days 

Joint pains since 15 days ( increased pain since a week ) 

Slurred speech since 3 days 

Shortness of breath since 5 days (grade 4 ) 

Patient was apparently asymptomatic a week ago and was able to do her daily chores. She is known diabetic and hypertensive for the past 14 years and on regular medication. 

On Telma H 40mg and on Azulix 1 MF ( glimiperide + metformin) 

The patient had a traumatic experience an year ago where she lost her son! Since then , patient started sleeping for longer time and also increased snoring 💤 since an year ( as said by the daughter ) 

3 months ago , she started consuming protein powder for weight loss , she used to consume only one meal a day that is in the afternoon and used to drink protein powder both morning and evening. No h/o exercising** 

(Replaced her morning and evening meals with protein powder ) 

2 months ago : H/O  fall due to sudden loss of balance breaking her left wrist for which she went to a local RMP and was suggested an Ayurvedic slab for the left wrist ! 

15 days ago : C/O joint pains (especially knee) 

She continued taking the protein powder,  until a week ago she went for the removal of the Ayurvedic slab and after she got home she developed 

Pedal Edema : pitting type , sudden in onset 

Facial puffiness  ++ 

Shortness of breath ( grade 4 , MMRC ) 

Edema over the hands and feet and face 

DECREASED URINE OUTPUT SINCE 5 days. 

She could walk a week ago and complained of aggravating pain in the BILATERAL KNEE JOINT. 

3 days ago she was unable to walk , unable to do her daily chores and unable to talk properly (slurred speech).

{?UREMIC ENCEPHALOPATHY} (blood urea: 154 mg/DL) 

Shortness of breath increased and she was presented to us on the morning of 29/3/2022 

USG : 

CXR - PA VIEW  (?) 

No H/O Burning micturition, hematuria , fever 

Vitals : 

Temperature: afebrile (98.3 degrees F) 

Pulse rate: 91bpm 

Respiratory rate :21cpm 

Spo2: 88 @ R.A , 96 on 11 lit O2 

Blood pressure : 180/110 (as of today morning)

GENERAL PHYSICAL EXAMINATION: 

Patient is known obese (?class 1) for the past 20 years 

Patient is conscious /coherent /cooperative 

No signs of pallor , icterus , cyanosis , clubbing or lymphadenopathy! 

SYSTEMIC EXAMINATION : 

Scaphoid 

Non tender 

Tubectomy scar + 

No guarding 

Bowel sounds heard+ 

CVS : S1 S2 + , no murmurs 

CNS: NAD ( ?dysarthria due to ?high urea levels?) 

RS: BAE+ , ? 

Provisional diagnosis : ?CHRONIC RENAL FAILURE ?diabetic nephropathy ?uremic encephalopathy 

Chronic renal failure due to ?INCREASED PROTEIN POWDER CONSUMPTION 

TREATMENT : 

1)  TAB . Lasix 40 mg PO/BD 

2) TAB. Nodosis 500 mg PO/BD 

3) TAB. Shelcal CT 500 mg PO / OD 

4) TAB. Orofer XT 1 tab PO /OD 

5) TAB. PAN 40 mg PO/OD 

6) INJ. Erythropoietin 4000 IU SC. Weekly once

7) TAB. Nicardia 20 MG PO/TID