Shailesh Patil

 54 year old man, with Hotel Business in Cherlapally since 10 years came to Kamineni hospital with C/O decreased appetite since 2 months after dialysis at kamineni C/O dyspnea grade 3 since 2 monthS C/O generalised weakness since 2 months C/O decreased appetite  C/O seizures (GCTS) on 23rd September 2020 in night ( MEDICATION TAKEN) O/E No fever spikes. Complaints of drowsiness since yesterday BP: 90/60 mmhg PR : 82 bpm RR: 22   CVS : S1 S2 heard no murmurs RS: BAE+ Coarse crepts heard diffusely present CBP:  Hb - 8.6 g/Dl TC - 8800  RBC - 2.95 ( Normocytic Hypochromic ) PC - 40,000 GRBS- 148 mg/Dl RFT: Urea : 101 creat: 4 uric acid : 5.1 Ca :8.2 P : 2.2 Na: 134 K: 4.5 Cl: 99 ABG: pH : 7.4 pCO2: 20.8 pO2: 121 HCO3 : 14 BEB- 8.3 BEecf : 9.4 SpO2 : 97.7% PAST HISTORY- Patient is an alcoholic since 10-15 years. Half bottle daily Epileptic since 6 years , monthly one episode (Epitoin - still continues) Admitted in Gandhi hospital 3 years back for that Diabetic since 6 years ( Initially on

 26/M btech,completed 3yrs back non alcoholic and a non smoker , developed vomitings 4-5episodes on23rd December: yellow colored,non bilious,non blood stained contained foodparticles/water. Then after patient used to have vomitings every day 2-3episodes or at times multiple episodes for  one &half month i.e till feb 11th    After 15days of onset of vomitings i.e in January patient went to Suryapet hospital and there for the first time he was said to have high bp-170mmhg and brain imaging was done .Used anti hypertensive drugs for 10days and stopped On February 12th he presented with : 1-multiple episodes of vomitings a day before,2-he noticed decreased urine output since January  3- intermittent shortness of breath on walking for long distance 4-spasm of both calves since 5-6yrs monthly twice/thrice only night times due to which he used to get up from his sleep His creatinine was 15mg/dl On February 13th he was referred to NIMS  i/v/o renal biopsy.There his shortness of breath was

1) anatomical diagnosis -? Kidney ? Cardiac??         Liver???                                                                        Etiological diagnosis -  ?? Nephrotic syndrome secondary to the diabetic nephropathy  or CKD.      2)Reasons for I) Azotemia : impaired renal excretion of urea and creatinine secondary to CKD.  II) Anemia : decreased erythropoietin.  III Hypoalbunemia: capillary basement membrane and podocytes damage. IV)  acidosis: acidification of urine is lost.                                       3) Rationale : syp potchlor was given because of the hypokalemia.. Inj. NaHCO3 was given because of metabolic acidosis ..Insulin and antihypertensives are given because known case of DM and HTN. Orofer XT was given because of anemia.. Inj. Lasix was given to decrease her volume overload. Spironolactone was given it was a potassium sparing diuretic.Calcium was given to the patient  because of hypocalcemia secondary to CKD. Indications of NaHCO3:metabolic acidosis in cardiac