19100006006 CASE PRESENTATION

 LONG CASE:

CHEIF COMPLAINTS:

62 year old male patient resident of Nalgonda farmer by occupation came to the hospital with

Chief complaints of 

Involuntary movements of Left lower limb since 1 year

Stiffness of all 4 limbs since 6m

Difficulty in swallowing since 2m

HOPI 

Patient was apparently asymptomatic 2 years back then he developed tremors which was mainly present in Left upper limb   after 1 year to  Left lower limb  which was gradual in onset, occurs at rest, subsides by voluntary movements and also subsides during sleep as told by family members. 

Tremors decreased with levodopa medication. 

 Rigidity since 6m, which made him stiff and is responsible for his flexed attitude.

He has history of difficulty in initiation of  movements , to start there is clumsiness of movements  and now difficulty to perform his day to day activities without assistance like going to bathroom. 

Difficulty to start walking and getting up from chair .

Difficulty in climbing stairs without assistance.

Difficulty in  wearing clothes and removing clothes

He is unable to wear and remove footwear without assistance because of stiffness.

 No history of slippage of footwear

No history of weakness in upper and lower limbs.

He has history of  falls (3-4 times)

He has history of postural instability

No history of giddiness

He has history of dysphagia since 2 months which is gradual in onset,  episodic in

 nature which was initially to solids and later slowly to liquids.

Dysphagia more to solids than liquids 

No history of  regurgitation

No history of heart burn.

No history of pooling of saliva.

No history of thyromegaly (any neck swelling)

 His relatives told that his voice has turned into slow dull and soft.

No history of headache

No history of vomiting

No history of siezures

No history of Fever 

No history of head injury

No history of jaundice

No history of STD

PAST HISTORY

History of similar complaints , 2yrs back, tremors in the Left upper limb which subsided gradually with medication, (levodopa.) Started on od dose initially and increased to Tid dose due to recurrence of tremors after 4-5 hrs and later to Qid dose since 3m 

 No h/o Diabetes, systemic hypertension, bronchial asthma, pulmonary koch’s, epilepsy, CVA, CAD, and Thyroid disorder

Personal History

Diet: Balanced

 Appetite: Normal

 Bowl/Bladder:Regular

 Sleep: Increased duration, excessive day time sleepiness

 Addictions: Non smoker and non alcoholic

Family history

 His wife is schizophrenic patient. 

GENERAL EXAMINATION

Patient conscious, cooperative, Moderately built and moderately nourished

Masked facies characterised by 

Infrequent blinking with staring look 

(Spontaneous ocular movements are lacking)

Loss of facial expressions ( blank) 

Widened palpebral fissure

 Coarse and static tremor of Left lower limb

Rate of blinking of eye is reduced 

Left hand has contractures

And fixed flexion deformity

GCS 15/15

Height-175cms   Weight-65kgs

 No pallor, No icterus, no cyanosis, no clubbing , no lymphadenopathy, no edema,no koilonychia

VITAL DATA:

 Temp: 100.2 F

PR: 85/min regular, normal volume, normal character, no radio radial and no radio femoral delay 

BP: 100/70mmhg in Left upperlimb on supine

 position 

On standing 100/60 mmHg  in same limb

 RR:16/min 

CNS :

HIGHER MENTAL FUNCTIONS:

Patient is oriented to person place and time 

Right Handed person, studied upto 4th standard.

Conscious, oriented to time place and person.

Speech : slow, and monotonous speech without any fluctuations.

Hypophonia 

Memory:  recent and remote memory intact

 No delusion and hallucinations

Emotional lability  absent.

MMSE : 22/30

CRANIAL NERVE EXAMINATION:

1st   : Normal

2nd  :  visual acuity is normal

           visual field is normal

           Normal fundus:  fundal glow present.

3rd,4th,6th  :  pupillary reflexes present.

                      EOM full range of motion present

5th             :  sensory intact

                      motor intact

7th             :  normal

8th             :  No abnormality noted.

9th,10th     : palatal movements present and equal.

11th,12th   : normal.

MOTOR EXAMINATION:     

   BULK    :     normal                             

   TONE    :  Hypertonia in all 4 limbs.

Leadpipe rigidity is seen in Left upper Limb.

 Cog wheel rigidity is seen in Left  wrist > right

       

INVOLUNTARY MOVEMENTS: 

Resting Tremors present 

Describing the involuntary movements:

1. Involuntary movements i.e.  tremors observed when patient is unaware 

2.Body part affected - Left lower limb

3. Frequency of movement -  coarse

4. Amplitude of Movement - low amplitude

5. Timing of movement - predominantly at rest and subsided on voluntary movement

6. Aggravated at rest and relieved on voluntary activity

 7. Static tremor.

8. Tremor is more prominent in left lower limb unilateral.

   POWER      : 

                 U/L.               L/L

Rt            4/5                 4/5

Lt             4/5                 4/5

   SUPERFICIAL REFLEXES:

   CORNEAL    ;   LE: present.        RE:  present       

   CONJUNCTIVAL : LE:  present    RE: present

   ABDOMINAL   :   present

   PLANTAR    :   Flexor in both limbs

   DEEP TENDON REFLEXES:

   BICEPS                       ++                                ++

   TRICEPS                      ++                             ++                                         

   SUPINATOR                ++                              ++                                              

   KNEE                            +++                        +++                                          

   ANKLE                         +                           +                                          

    Clonus   :  absent

Glabellar tap :  present

SENSORY EXAMINATION:  

SPINOTHALAMIC SENSATION:

Crude touch.    Normal

pain.          Normal

temperature.   Normal

DORSAL COLUMN SENSATION:

Fine touch.     NAD

Vibration.       NAD

Proprioception.    NAD

CORTICAL SENSATION:

Two point discrimination.  NAD

Tactile localisation.   NAD

stereognosis.   NAD

graphasthesia.      NAD

CEREBELLAR EXAMINATION:

  Normal

 No  hypotonia and  pendular knee jerk :  absent

  Intention tremor  : absent

  Rebound phenomenon  absent

  Nystagmus: absent 

  Titubation: absent

  Rhombergs  test :  couldn't  elicit

GAIT: 

Festinant gait, 

Short shuffling gait.

Stance: Patient mildly bending forward

Difficulty in initiation of movements , 

Freezing suddenly

Started walking with rapid, short shuffling steps

Paucity of automatic movements of both upper limbs ( no swinging movement of arms)

Impaired balance on turning.

 unable to perform tandem walking.

SIGNS OF MENINGEAL IRRITATION: absent

Autonomic functions: 

No resting tachycardia

No postural hypotension

No  excessive sweating

Other systems examination

 CVS: 

S1,S2 heard, 

no murmers

RESPIRATORY SYSTEM:

Chest - symmetrical, No paradoxical movements

Normal vesicular breath sounds heard

No abnormal/added sound

ABDOMEN:

 Abdomen is soft, non tender.

No organomegaly

No ascites

Bowel sounds+ 

Right upper limb Cog wheel rigidity

Leadpipe rigidity??

Handwriting

Left upper limb Cog wheel rigidity

Tone

GAIT

 

1)Lt triceps

2) Glabellar tap present

3)Lt triceps reflex

4)Lt Supinator Reflex

5)Rt Biceps

6)Rt Triceps

7)Rt Supinator

8)Resting Tremors

9)Rt Ankle Jerk

10)Lt Ankle Jerk

11)Lt Plantar Reflex

12)Rt Plantar Reflex

13)Knee Jerk

14)Lt Biceps

CBP : 

HB : 12.3g/dl

TLC : 6,600

PLATELETS. .2.14 lakh

RBS :97 mg/dl

Sr. Cr : 1.1 mg/dl

Sr. Urea : 33 mg/dl

 Na: 139 meq 

K : 4.0 

Cl: 101 

LFT : 

TB : 2.39

DB :  0.8

ALT :34

AST: 30

ALP:  131

Albumin: 4 

TP :  6.3 

ECG

CXR

Provisional Diagnosis : 

Idiopathic  Parkinson's disease 

---------------------------------------------------------------------------------------------------

SHORT CASE 1:

This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.

Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.

I have been given this case to solve in an attempt to understand the topic of "Patient Clinical Data Analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

Following is the view of the case

60 years old male daily wage labourer by occupation was brought to the casuality with the 

1)Complaints of loss of speech since 2 days

2) Weakness of right upper limb since 2 days

3) Deviation of mouth to left side since 2 days

HOPI- 

He was apparently asymptomatic 2 days ago.Then he developed slurring of speech which was sudden in onset and  progressed to the present situation i.e.  complete loss of speech. (Aphasia)

He also developed weakness in his right upper limb at around 10:00 pm one day before admission.He is unable to move his right upper limb, (complete paralysis),It was sudden in onset. non- progressive in nature.

He developed mild deviation of mouth to Left side, since 2 days, which is sudden in onset. Non progressive in nature, Deviation was obvious during eating and when attempting smiling.Loss of nasolabial fold in the right side.

No h/o convulsions

No h/o headache

No h/o  unconsciousness

No h/o vomiting 

No h/o head injury

No h/o fever 

No h/o bowel and bladder disturbances 

No h/o chest pain

No h/o palpitations 

no h/o syncopal attacks.

Past h/o:

No history of similar complaints in the past.

Underwent cataract surgery for right eye last year in October. 

H/o trauma over the right wrist present 10 years back. He did not get any surgery for the fracture hence developed a malunion union of colles fracture in right upper limb.

Not a k/c/o DM,HTN, CAD, CVA,Epilepsy 

Personal h/o:

Consumes a Mixed diet. Sleep pattern is regular. Has a normal appetite.

He used to consume 250 ml of alcohol and 40 beedis per day since 15 years of age. Has reduced to 20 beedis/day in the last 5-6 years. 

Bowel and bladder habits are normal.

Married 35 years ago Has 2 children

Family h/o: No significant family history

General physical examination: he is conscious, cooperative, moderately built and moderately nourished.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, Edema.

GCS:15/15 

Vitals:

PR- 88 bpm, regular in rhythm, voluminous, felt in all peripheries, no radio-radial delay, no radio-femoral delay

BP- 110/80 mm Hg measured in left upper limb in supine position 

RR- 16 cpm, Thoraco-abdominal

Temperature- 98.4 degrees F

SpO2- 99% @ RA

GRBS- 106 mg/dl

NEUROLOGICAL EXAMINATION:

I) Higher mental functions- 

Patient is conscious, cooperative.

Speech : Motor aphasia 

Other findings could not be elicited.

II) Cranial nerves-

1- could not be elicited 

2-

i) Visual acuity – N 

2)Fundus . Normal

3,4,6- 

Test	Right eye	Left eye
Extra-ocular movements-	full in all directions	full in all directions
Pupil	Normal and symmetrical	Normal and symmetrical
Direct Light Reflex	Present	Present
Consensual Light Reflex	Present	Present
Accommodation Reflex	Present	Present
Ptosis	No	Present
Nystagmus	Absent	Absent
Horner’s syndrome	Absent	Absent

5- 

Test	Right	Left
Sensory -over face and buccal mucosa	Normal	Normal
Motor – masseter, temporalis, pterygoids	Normal	Normal
Reflexes- Corneal reflex	Present	Present
Conjunctival reflex	Present	Present
Jaw jerk	Present	Present

7-

	Right	Left
Nasolabial fold.	Absent	Present

Deviation of mouth  absent.    Present

b) Sensory – 

Test	Right	Left
Taste of anterior 2/3rds of tongue(salt/sweet)	Could not be elicited	Could not be elicited
Sensation over tragus	Could not be elicited	Could not be elicited

c) Reflex – 

Test	Right	Left
Corneal	Present	Present
Conjunctival	Present	Present

d) Secretomotor –

Moistness of the eyes/tongue and buccal mucosa present in both right and left sides.

8-

Test	Right ear	Left ear
Rinnes	Could not be elicited	Could not be elicited
Webers	Could not be elicited	Could not be elicited
Nystagmus	Could not be elicited	Could not be elicited

9,10-

i) Uvula, Palatal arches, and movements- Centrally placed and symmetrical

Test	Right.	Left
Gag reflex.	Present	Present

11-

Test	Right.	Left
trapezius	N	N
sternocleidomastoid	N                N

12  Test	Right	Left
Tone	Normal	Normal
Wasting	No	No
Fibrillation	No	No
Tongue Protrusion to the midline and either side	Normal	Normal

III) Motor system:

A) Bulk	Right	Left
Inspection	Normal	Normal
Palpation	Normal	Normal
Measurements: upper limb 10cm above and below acromion
Lower limb 18 cm above and 10 cm below tibial tubercle
B) Tone	Rt	Lt
Upper limbs	Decreased.	Normal
Lower limbs	Normal	Normal
C) Power  Right upper limb       0/5 Left upper limb.        5/5 Right lower limb.      4/5 Left lower limb.        5/5
D) Reflexes:
Superficial:
- Corneal.   Normal
- Conjunctival.   Normal
- Abdominal : absent
- Plantar   :  RT :extensor	Lt: flexor
Deep Tendon:	Rt	Lt
- Biceps	+++	++
- Triceps	+	+
- Supinator	++	+
- Knee jerk	++	++
- Ankle jerk	+	+
- Clonus.    Absent
Gait : circumduction gait
G) Involuntary movements	Absent

IV) Sensory system- could not be elicited

V) CEREBELLAR SIGNS-

Titubation absent

Nystagmus absent

Hypotonia absent

Rebound phenomenon absent

Intention tremor absent

Pendular knee jerk absent

VI) AUTONOMIC NERVOUS SYSTEM

Postural Hypotension absent

Resting tachycardia absent

Abnormal sweating absent

VII) SIGNS OF MENINGEAL IRRITATION

Neck stiffness absent

Kernig’s sign negative

Brudzinski’s sign   negative

EXAMINATION OF OTHER SYSTEMS:-

 CARDIOVASCULAR SYSTEM:  

JVP not raised

Apex normally placed, 

no Palpable P2,

 Heart sounds –s1s2 present  normal, No thrills/murmurs

B) RESPIRATORY SYSTEM:

Chest - symmetrical, No paradoxical movements

Normal vesicular breath sounds heard

No abnormal/added sound

C) ABDOMEN:

 Abdomen is soft

No organomegaly

No ascites

Per-rectal examination- NAD

Investigations:-

CBP:

Hb- 14.2 gm/dl

TLC-13,000/cu. mm 

PLT - 2 lakhs/cu. mm

RBS- 112 mg/dl

BGT- O positive

BT-2 min 30 sec

CT -4 min 20 sec

LFT:

TB - 1.20 mg/dl

DB-0.30 mg/dl

AST-34 IU/L

ALT-39 IU/L

ALP- 608 IU/L

TP -7.5 gm/dl

Albumin - 3.9 gm/dl

RFT:

Urea- 35 mg/dl

Creatinine- 1.1 mg/dl

Uric acid- 5.1 mg/dl

Calcium- 9.2 

Phosphate- 3.6

Sodium- 135

Potassium- 4.7

Chloride- 99

CUE:

Colour - pale yellow

Appearance-clear

sp.gravity-1.010

Albumin : +

Sugar -nil

pus cells- 4-5

USG abdomen - Done in outside hospital at 13/05/2022 

Impression: 

- Altered hepatic echotexture with multiple hetero echoic lesions -?nature.

- Left renal calculi

- Left renal cortical cyst

ECG- 

2D Echo- 

CXR- PA VIEW:

CT Brain-

Multiple acute infarcts in both cerebral hemispheres & right cerebellum- Suggestive of embolic stroke.

---------------------------------------------------------------------------------------------------

SHORT CASE 2:

Patient came to our hospital on January 15,2022 follow up case. 

30 years old female homemaker by occupation came to the General Medicine OPD with the 

January :  

- B/L joint pains (knees) since 10 months

     - B/L itching in the upper aspect of chest and neck since 10 months 

       

H/O P.I.: Patient was apparently asymptomatic 10 months ago. Then she developed symmetrical b/l joint pains in the knees which was insidious in onset, gradually progressive, no aggravating factors and relieved on medication i.e. TAB. HYDROXYCHLOROQUINE 200 mg 

Associated with morning stiffness.

Around the same time she developed itching over neck and upper chest area. As a result of the itching, the area was initially red and turned black. 

C/O Alopecia since 10 months. It was gradually progressive leading to severe hair loss over the past 10 months. Associated with thinning of hair.

C/O bilateral pitting type of pedal Edema and Edema over the dorsal aspect of hands.

C/O generalised pain.

C/O Difficulty in walking.

C/O distal muscle weakness manifested in the form of : difficulty in mixing food, eating with hands, buttoning-unbuttoning of shirt, combing of hair.

C/O proximal muscle weakness manifested in the form of : difficulty in getting up from squatting position, getting objects present at a height.

C/O Dyspnea on exertion (NYHA- 3), gradually progressive since 4-5 months.

C/O vaginal discharge since 7-8 months. It was initially curdy white which later changed to watery discharge. Associated with itching. 

C/O weight loss of 4 kg over the last 10 months.

C/O oral ulcers and genital ulcers since 10 months.

-No h/o fever, cold, cough.

  During  March : 

        - B/L joint pains associated with edema over legs upto knee joint  including dorsum of foot since 4 days

- c/o dyspnea at rest since 4 days

-c/o cough since 4 days

   

        

H/O P.I.: Patient was apparently asymptomatic 12 months ago. 

 Then she developed symmetrical b/l joint pains in the knees which was insidious in on set, gradually progressive, no aggravating factors and relieved on medication i.e. TAB. HYDROXYCHLOROQUINE 200 mg 

Associated with morning stiffness.

Around the same time she developed itching over neck and upper chest area. As a result of the itching, the area was initially red and turned black. 

C/O Alopecia since 12 months. It was gradually progressive leading to severe hair loss over the past 12 months. Associated with thinning of hair.

 

C/O proximal muscle weakness manifested in the form of : difficulty in getting up from squatting position, getting objects present at a height.

No history of distal muscle weakness manifested in the form of : 

No history of difficulty in mixing food, eating with hands, buttoning-unbuttoning of shirt,

-h/O Dyspnea on exertion (NYHA- 3), gradually progressive since 6 m

-she visited many local RMPs,received pain killers as there is no improvement, she visited a health centre 2 months back.

Following are the clinical images when she visited health centre 4 months back:

Her X RAYS 2 MONTHS BACK:

Treatment given 2 months back:

And 1.tab.wysolone 50mg po od

2.syp.mucaine 10ml/po/tid

3.tab.ultracet 1/2 po/QIT

4.candid cream for L/A is advised

Patient was referred to other health centre for muscle biopsy.

Patient went to health centre,

her ANTI NUCLEAR ANTIBODY IMMUNOFLUORESCENCE showed homogeneous pattern.Intensity 4+ associated antigens involved-ds DNA, antihistones.

MYOSITIS PROFILE was done which showed MDA-5 , PL-7, Ro -52 all three were strong positive

HRCT WAS DONE ON 21/1/22

IMPRESSION: Few patchy areas of ground glass opacities in peri brochovascular distribution-s/o pneumonitis .Corads-4

She didn't undergo muscle biopsy as the doctors there advised it is not necessary 

THEY PRESCRIBED:

1.TAB.CALTEN

2.TAB.AUGMENTIN

3.TAB.NAPROXEN SODIUM

4.TAB.FOLVITE

5.CANDID CREAM

6.TAB.WYSOLONE

7.TAB.ESOMEPRAZOLE

8.TAB.SODIUM ALENDRONATE WEEKLY ONCE.

Past history: 

Not a k/c/o DM, HTN, BA, epilepsy, Asthma, CVA, CAD.

                 Had similar complaints in the past 2 months.

Menstrual h/o: AOM- 11 years

                3/25-28, regular , no pains, no clots.

Marital h/o: ML- 14 years, NCM

                 Primary infertility (Nulligravida) 

Has recently adopted a girl from her sister-in-law. 

Family h/o: No similar complaints in the family 

Personal h/o: 

            Diet- Mixed

           Appetite- Decreased

           Sleep- Inadequate since 12 months. WAKES AT 2 AM -3AM BECAUSE OF PAIN IN LEGS.

           Bowel and bladder habits- IRREGULAR

C/O LOOSE STOOLS FOR 4 DAYS FOLLOWED BY CONSTIPATION FOR 3 DAYS SINCE 8 MONTHS

           No addictions

           No known drug allergies 

General physical examination: The patient is conscious, coherent, cooperative well oriented to time, place and person. She is moderately built and moderately nourished. 

 Skin lesions present

Pallor- present

No icterus, cyanosis, clubbing, lymphadenopathy.

Pedal Edema- present 

O/E:

Patient images after treatment of 2 months:

Vitals: 

Temperature- Afebrile

BP- 120/80 mm Hg

PR- 86bpm

RR- 18cpm

SpO2-98 on RA

SYSTEMIC EXAMINATION:

CNS : 

HMF- patient conscious

        oriented to place/time/person

no h/o aphsia/dysarthria

no h/o dysphonia

no h/o memory loss

no h/o emotional lability

MMSE- 30

cranial nerves- intact

MOTOR SYSTEM 

                                              Right.         Left

Bulk:     Normal

Tone:               ul.            normal.         Normal

                         LL.         normal           Normal

Power    

                   RT.          Lt 

Deltoid       4/5         3/5

Supraspinatus. 4/5.        3/5 

Infraspinatus.   4/5.    3/5 

Rhomboid.        3/5.  3/5 

Serratus anterior 4/5 3/5

Pectoralis major.   3/5. 3/5 

Latismus dorsi.    4/5.  4/5 

Biceps     5 /5     5/5

Triceps     5/5.   4/5 

Brachio radialis    5/5 5/5 

               

               iliopsoas                5/5.              5/5

   adductor femoris            4/5.               4/5

       gluteus medius             3/5.               3/5

   gluteus maximus            3/5.               3/5

              hamstrings            3/5.               3/5

quadriceps femoris            3/5.               3/5

tibialis anterior.                   5/5.               5/5

tibialis posterior.                 5/5.               5/5

Reflexes.  

   Superficial reflexes

                       Right.           Left

Corneal.            P                  P

Conjunctival    P.                  P

Abdominal.      +               +

Plantar            flexor.    Flexor

    Deep tendon reflexes 

                     Right.             Left

Biceps.          ++                 ++

Triceps.         +                 +

Supinator.     +                    +

Knee              ++                 ++

Ankle.            +                  +

 

SENSORY SYSTEM 

                                    RIGHT.           LEFT

SPINOTHALAMIC 

             crude touch.   N.                   N

                 pain.             N.                   N

            temperature.   N.                   N

post:

             fine touch.      N.                   N

             vibration.        N.                   N

     position sensor.    N.                   N

 cortical 

 2 point discrimination  N.                   N

tactile localisation.        N.                   N

CEREBELLUM

titubation - absent

ataxia - absent

hypotonia.         Absent

CVS- S1, S2 sounds heard. No murmurs

RS- BAE+ NVBS heard

P/A- Soft, non tender, Bowel sounds heard

INVESTIGATIONS- 

Chest X RAY-

ECG:

 USG ABDOMEN ON 15/3/22-

IMPRESSION: RIGHT RENAL CORTICAL CYST WITH WALL CALCIFICATION. 

2D ECHO ON 15/3/22

EF-60%

TRIVIAL AR/MR

GOOD LV SYSTOLIC FUNCTION 

NO DIASTOLIC DYSFUNCTION. 

Sputum culture-presence of branching and filamentous acid fast bacilli are seen 

?Nocardia species 

HEMOGRAM

HB-9.9

TLC-9600

N/L/M/E-90/6/2/2

PLT-1.77

PCV-29.2

RBC-3.56

SERUM CREATININE-0.9

Na-137,k-3.5,Cl-98

LFT:TB-0.82,DB-0.24,AST-16,ALT

18,ALP-137,ALB-2,A/G: 0.62

GRBS-240MG/DL(8 AM)

Spot urine protein -27

Spot urine creatinine-19

Spot urine creatinineratio-1.42

PT-16 sec

APTT-32 sec

INR-1.11

24 hour urinary protein:59.9 mg/dl

24 hour urinary creatinine:0.5g/day

DERMATOMYOSITIS  with pulmonary Nocardiosis. (Resolving)

With mild  proximal myopathy?

---------------------------------------------------------------------------------------------------

CRITICAL APPRAISAL:

Clinical and cost-effectiveness of oral sodium bicarbonate therapy for older patients with chronic kidney disease and low-grade acidosis (BiCARB): a pragmatic randomised, double-blind, placebo-controlled trial

P --- patients with CKD ,EGFR less than 30 not on hemodialysis

I- sodium bicarbonate 3gm/day for 2 years 

C - placebo 

O - Outcomes : 

We measured outcomes at baseline and 3, 6, 12 and 24

months. The primary outcome was the between-group

difference in the Short Physical Performance Battery

(SPPB) at 12 months, adjusted for baseline values. The

SPPB is a 12-point measure of lower limb strength and

balance, with higher values denoting better function,

that predicts future disability, need for care and death. The minimum clinically important difference

has been derived for the measure [16].

Secondary outcome measures were generic (EuroQoL

EQ-5D-3L) [19] and disease-specific (Kidney Disease

Quality of Life) [20] health-related quality of life, 

anthropometry (weight, mid-arm muscle circumference, triceps

skinfold thickness, mid-thigh circumference), physical

performance (6-min walk speed, grip strength) and renal

function

Conclusion : 

Our results suggest that at least for patients aged 60 and over with CKD GFR categories 4 and 5, 1.5 to 3 g per day of oral bicarbonate does not produce any health benefits and may be associated with net harms. Whilst other indications for control of acidosis exist (for example high potassium concentrations), evidence from the current trial suggests that the additional cost, treatment burden and side effects of oral bicarbonate may not justify its use in older people with advanced CKD and mild degrees of metabolic acidosis (i.e. serum bicarbonate concentration < 22 mmol/L). Raising bicarbonate levels by an amount sufficient to produce useful clinical effects will require larger doses than we used in this trial and is likely to require a ‘treat-to-target’ strategy. However, such doses may not be tolerated by many older people. Alternative strategies, such as the use of hydrochloric acid binders, may provide a way round this issue, but such agents need to be tested against current practice in representative groups of patients, using a range of outcomes relevant to older people including physical function, quality of life and deterioration of renal function.

https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-020-01542-9