48year old male complaints of involuntary movements and pedal oedema

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48year old male resident of kottapalle, nalgonda.came to the casualty with c/o 1episode of involuntary movements -bilateral upper limbs lasted for 10mins.(sparing lower limbs)
Tonic seizures associated with tongue bite, froathing,uprolling of eyes.
No involuntary micturition or defecation.
Post ictal confusion lasted for 10 hours.
No further episodes after that .
Patient was apparently asymptomatic 4years back had h/o pedal oedema,sob (on and off ), aggrevated since 15 days .
SOB -GRADE III-IV,NOT ASSOCIATED WITH ORTHOPNEA,PND ,GIDDINESS,SWEATING,SYNCOPE.
PEDAL OEDEMA-GRADUAL ONSET, PROGRESSIVE TO ANASARCA.
NO URINE OUTPUT SINCE ONE DAY .
2YEARS BACK HAD H/O TRAUMA CAUSED LEFT FEMUR FRACTURE WHICH WAS OPERATED .
Walked with support since 2years.
Diagnosed with kidney disease?CKD at the time of operation 2years back, asked to followup regularly which patient did not.
DENOVO HYPERTENSIVE.
PERSONAL HISTORY-
HE USED TO WORK AS FARMER , DUE TO TRAUMA HAPPEND 2YRS AGO, STOPED WORKING.
APPETITE-NORMAL
DIET-MIXED
BOWEL AND BLADDER MOVEMENTS-REGULAR
ALCOHOL CONSUMPTION SINCE 20YEARS
(From saved money,toddy previously,now consumes whiskey 90-180ml/day)
NSAID ABUSE+ SINCE 2YEARS

On examination
Pt is in altered sensorium,irrelevant talk since seizure episode
GCS:E4V3 M4
swelling of right hip ,thigh and abduction of hip towards evening 
Painful on palpation
TEMP-AFEBRILE
PR-88BPM
RR-30CPM
SPO2-99
GRBS-229
CVS-S1S21+
RS-BAE+NVBS
P/A-SOFT,NON TENDER,B/S+

PROVISIONAL DIAGNOSIS-
CKD (STAGE V)WITH HYPERTENSION,DM-II(DENOVO), SEIZURE SECONDARY TO?UREMIA?, SEVERE METABOLIC ACIDOSIS WITH UREMIC ENCEPHALOPATHY.
TREATMENT-
1.FLUID RESTRICTION(LESS THAN 1.5L/DAY)
2.SALT RESTRICTION(LESS THAN 2.4 GM/DAY)
3.INJ.LASIX 60MG  IV/STAT,---40MG IV /BD
4.INJ.NAHCO3 50 MEQ IV /STAT  15MINS TO 20MEQ IN 50ML NS OVER 45MINS
5. GRBS MONITORING
6. I/O CHARTING.
INVESTIGATIONS  ON 16/11/2021
HEMOGRAM 

SERUM CREATININE -9.3mg/dl
BLOOD UREA-161mg/dl
SEROLOGY-HIV,HBsAG,HCV NEGATIVE
INVESTIGATIONS ON 19/11/2021
HEMOGRAM
ECG
RFT
Serum iron
ABG @6:30PM
INVESTIGATIONS ON 20/11/2021
ABG ON 20/11,1AM
ABG @5AM
Hemogram

INVESTIGGATIONS ON 21/11/2021
ABG @6AM
CLINICAL IMAGES

SOAP NOTES ON DAY 1

S- 

O-pt is comatose, not responding to painful stimuli
GCS-E1V1M1
pupils-mid dilated,not reacting to light.
deep tendon reflexes :absent.
Afebrile
RR:22/min,
PR-107/min
BP-100/40mmhg with inj norad-ds @24ml/hr,inj dobutamine @14ml/hr,inj vasopressin 1.2ml/hr

CVS:S1+S2+
R.S:. BAE+NVBS              spo2:94%with 8 lit o2
P/A;abdominal tightness+,bs+

I/O:2000ml/10ml

Right lowerlimb skin traction was applied
Patient underwent one session of haemodialysis with 2 PRBC transfused.
bicarbonate replaced during dialysis :300meq with low UF due to his hypotension.

Abg -report awaited.

A-CHRONIC RENAL FAILURE WITH DENOVO DM2
GTCS (TONIC) SECONDARY TO ? URAEMIA -RESOLVED
SEVERE METABOLIC ACIDOSIS SECONDARY TO RENAL FAILURE -REFRACTORY 
SEVERE ANAEMIA SECONDARY TO ?BLOOD LOSS
SHOCK(? CARDIOVASCULAR) SECONDARY TO ACIDOSIS.
RT SUBTROCHANTERIC FEMUR FRACTURE.
URAEMIC ENCEPHALOPATHY





P- Review USG of right hip to look for collection in the posterior dependant aspect
ionotrope support
(inj noradrenaline 2 amp in 46mlns@24ml/hr,inj dobutamine 1 amp in 45mlns@14ml/hr
inj vasopressin 1amp in 48ml ns @1.2 ml/hr
taper as per MAP)
2.RT feeds -milk and free water
3.Tab Levipil 500mg/RT/bd.




Q-High anion gap metabolic acidosis in this case most likely due to renal failure,
cause for persistent acidosis inspite of replacement?
Can acidosis cause shock without decreasing myocardial contractility?

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