48 M with decreased urine output and pruritus

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CHIEF COMPLAINTS 

 50 year male resident of tippathi mandalam Nalgonda district ,farmer by occupation came with chief complaint of

Itching in the front and back and both upper arms since 2 months . 

Nausea , vomitting,loss of appetite since 7days 

Decreased urine output since 1day 

HISTORY OF PRESENTING ILLNESS 

At the age of 13 in 1986, the patient began his career as a lorry cleaner, accompanying a driver for the first two years before starting to drive the lorry himself at the age of 15. He continued in this profession until the age of 45 in 2019, driving 100km round-trip per day and working 4-6 days per week depending on his financial needs.

Five years ago, the patient started to feel easily fatigued and was diagnosed with high blood sugar at a local hospital. He was started on oral hypoglycemic agents (OHAs) but eventually switched to insulin as his blood sugar remained uncontrolled. For the past four years, he has been taking an inadequate dose of insulin (16-18U once a day instead of the prescribed twice a day), as he experienced hypoglycemic symptoms such as sweating, palpitations, and weakness intermittently when taking the full dose.

Two years ago, the patient suffered a thorn prick to his left second toe, which worsened despite treatment by a local practitioner for 15 days. Disarticulation of the toe was eventually performed at our hospital. For the past year, the patient has had on-and-off pitting pedal edema up to the knee level, without any associated breathing difficulties 

No history of fever ,headache ,rash ,joint pains ,no history of change in sleep pattern ,confusion ,altered sensorium ,no history of blood in stools, melena ,constipation .

Two months ago, the patient began experiencing nighttime itching on his back, which gradually spread to his buttocks, upper arms, and front. For the past week, he has had symptoms of nausea, loss of appetite, and decreased urine output, prompting his admission to our hospital for further management. There is no history of fever, difficulty breathing, or swelling in the ankles.

PAST HISTORY 

The patient was diagnosed with type 2 diabetes mellitus five years ago. For the first year, the patient used oral hypoglycemic agents, but for the past four years, he has been on insulin once daily. There is no history of hypertension, asthma, tuberculosis, epilepsy, or thyroid disorders. In October 2022, the patient experienced weakness in both their upper and lower limbs, making it difficult for him to get out of bed. The patient was diagnosed with hypokalemic paralysis, which was confirmed by a low serum potassium level of 1.7 mEq/L. After correcting the potassium level, the patient's strength in their limbs returned, and he was able to get up from bed. The patient was given syp potcklor for one week and did not experience any similar episodes thereafter.

FAMILY HISTORY 

No similar complaints in the family 

TREATMENT HISTORY 

The patient was diagnosed with type 2 diabetes mellitus five years ago. For the first year, the patient used oral hypoglycemic agents, but for the past four years, he has been on insulin once daily.

He takes inj insulin S/C once daily

SURGICAL HISTORY 

Two years ago, the patient suffered a thorn prick to his left second toe, which worsened despite treatment by a local practitioner for 15 days. Disarticulation of the toe was eventually performed at our hospital.

Patient underwent cataract surgery for his right eye 1-1/2 year back

PERSONAL HISTORY 

Daily Routine: This individual typically wakes up at 7:00am and proceeds to tend to his farm. He waters his fields and returns home by 10:00am to eat tiffin. At 11:00am, he heads back to the farm and works until 6:00pm. He takes insulin in the afternoon prior to eating lunch. Once he returns home, he takes a bath and has dinner around 8:00pm. He usually goes to bed by 9:00pm.

Family Life: The individual has two daughters, both of whom are married and have children.

Addictions: He has a habit of consuming umber and drinking alcohol and smoking cigarettes (biddis)

Alcohol -abstained since 1 year due to guilt over his health worsening day by day,but used to consume 90-180ml/day whiskey

biddis- stopped smoking one year ago (5-6bidis/day).

GENERAL PHYSICAL EXAMINATION 

Patient is conscious, coherent,co-operative.Moderately built and Moderately nourished.

PALLOR -absent 

ICTERUS -absent 

CYANOSIS -absent 

CLUBBING -absent 

LYMPHADENOPATHY -absent 

PEDAL EDEMA -absent 

VITALS 

TEMP-a febrile 

BLOOD PRESSURE -140/80mmHg right arm in supine position 

PULSE RATE -90bpm,regular rhythm,normal volume 

Jvp is not raised ,normal in character ,volume 

RESP RATE 18cpm thoracoabdominal 

SPO2-98%  in room air 

HEAD TO TOE EXAMINATION 

papules on the back, front, upper arms, and buttocks, and the Koebner phenomenon is present. In addition, there are dark hyperpigmentated patches on the back, front, and upper arms, and there is a thickened area probably plantar keratosis on the sole of the right foot. 

The second toe on the left foot is missing.

CVS

Elliptical & bilaterally symmetrical chest

-No visible pulsations/engorged veins on the chest

-Apex beat seen in 5th intercostal space medial to mid clavicular line

-S1 S2 heard

-No murmurs

RESPIRATORY SYSTEM

Upper respiratory tract normal

  Lower respiratory tract :

-Trachea is central

-Movements are equal on both sides

-On percussion resonant on all areas

-Bilateral air entry equal

-Normal vesicular breath sounds heard

-No added sounds

-Vocal resonance equal on both sides in all areas

CNS 

Higher mental functions

-Patient is conscious, coherent,co-operative.Oriented to time, place,person.

-Speech = Fluency,comprehension,repetition intact

-Memory =Recent,Remote,Immediate : Intact

Cranial nerve examination -

2 - Visual acuity RE-6/60,LE-CF 1mts

other cranial nerves are normal

Motor examination :

Bulk of muscle normal on both sides on inspection

Tone  

                          Right.             Left 

Upper limb.    Normal.           Normal

Lower limb.    Normal.           Normal

REFLEXES

                   Right.              Left

Biceps.       -                       -

Triceps.      -                       -       

Supinator.  -                        -

Knee.          -                        -

Ankle.         -                        -

Plantar.       flexor                  flexor

Sensory examination:

1.Spinothalamic:      R              L

Crude touch            +                +

Pain                         +                +

2.Posterior column:

Fine touch                +                +

Vibration     Reduced

ankle     - -                   --

          Knee.     --                   --

          Wrist.       6sec          6sec  

Position sense 

         LL.            Rt-6/10.          Lt --5/10   

3.Cortical

Stereognosis:     +             +

Graphesthesia    +.            +

CEREBELLUM:

Finger nose and finger finger test were normal

No dyadiadokokinesia 

No pendular knee jerk

Heel knee test : normal

PER ABDOMEN EXAMNATION

-Scaphoid

-No visible pulsations/engorged veins/sinuses

-Soft,non tender, no guarding and rigidity, no organomegaly

-Bowel sounds heard

INVESTIGATIONS 

X ray 

PROVISIONAL DIAGNOSIS

The patient is experiencing uremic symptoms as a result of chronic kidney disease (CKD), which include papular lesions on the upper trunk, back, buttocks, and upper arms, as well as the Koebner phenomenon. They also have a history of diabetic neuropathy and hypokalemic paralysis as of October 2022, and have been diagnosed with type 2 diabetes for five years.

An indication for dialysis in this patient is anuria and further uremic symptoms such as nausea and loss of appetite. Following the dialysis treatment on April 23rd, the patient's symptoms showed improvement.

After the dialysis procedure, the patient's renal function tests were evaluated.