70 YEARS OLD FEMALE WITH ACUTE KIDNEY INJURY(AKI) SECONDARY TO UROSEPSIS ON CHRONIC KIDNEY DISEASE(CKD) SECONDARY TO HYPERTENSION NEPHROPATHY.

 

70 YEARS OLD FEMALE WITH ACUTE KIDNEY INJURY(AKI) SECONDARY TO UROSEPSIS ON CHRONIC KIDNEY DISEASE(CKD) SECONDARY TO HYPERTENSION NEPHROPATHY.


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 comments on comment box is welcome.


MEDICINE CASE DISCUSSION:

I've 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.


VIEW OF THE CASE :

A 70 years old female, who is a housewife came to OPD with chief complaints of lower backache with generalised waekness(unable to sit) since 1 week and decreased urine output  since 3 days, bilateral pedal edema since 3 days.


HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic one week back then she developed  Bilateral loin pain radiating upto inner thigh since 2-3 years, which is increased from last one week associated with decreased urine output and bilateral pedal edema upto ankle.

She is evaluated as hyponatremic (dyselectrolytemia)

Na+ = 117 mEql/L

K+ = 2.8 mEql/L


PAST HISTORY:

She is a known case of CKD since 2016 and hypertension since 5 years

Not a known case of diabetes, asthma, epilepsy, tuberculosis 

She underwent HD (HEMODIALYSIS) in 2019.



TREATMENT HISTORY:

she is on conservative management along withHypertension on regular medication 

She underwent HD (HEMODIALYSIS) in 2019.


PERSONAL HISTORY:

Appetite-  loss of appetite 

Diet- mixed

Bowel habits- regular 

Bladder habits-  decreased urine output from 3 days

Sleep- adequate 

Addictions- no addictions

Allergies- no allergies



FAMILY HISTORY:

Insignificant 



GENERAL EXAMINATION:

Conscious, coherent and cooperative 

Well oriented to time, place and person 

Moderately built and moderately nourished 

Pallor- PALLOR PRESENT (severe)

Icterus- No icterus

Cyanosis- No Cyanosis 

Clubbing- No clubbing 

Generalised lymphadenopathy- No generalised lymphadenopathy 

Pedal edema- BILATERAL PEDAL EDEMA UPTO ANKLE

Malnutrition- No

Dehydration-  Mild



VITALS:


On 17.06.2021

Temperature - afebrile 

Pulse rate- 93 bpm

Respiratory Rate- 14 cycles per minute

Blood Pressure- 160/80 mm of Hg

GRBS- 152 mg/dl


On 18.06.2021 

Temperature - afebrile 

Pulse rate- 96 bpm

Respiratory Rate- 14 cycles per minute

Blood Pressure- 150/60 mm of Hg

GRBS- 152 mg/dl


On 19.06.2021

Temperature - afebrile 

Pulse rate- 84 bpm

Respiratory Rate- 14 cycles per minute

Blood Pressure- 170/90 mm of Hg

SpO2- 100% at room air

GRBS- 176 mg%



SYSTEMIC EXAMINATION:


CARDIOVASCULAR SYSTEM- S1 and S2 heart sounds heard, no murmers and thrills


RESPIRATORY SYSTEM- Bilateral air entry present with vesicular breath sounds and no added sounds. No dyspnoea, wheeze


CENTRAL NERVOUS SYSTEM- intact

Consciousness  - Conscious

Speecg - normal

Signs of meningeal irritation :

         Neck stiffness - no

         kerning's sign - no

Cranial nerves- normal 

Motor system - normal

Sensory system - normal 

Glassgow scale - normal


ABDOMEN- no organomegaly 

Shape - scaphoid

Tenderness - non tender

Palpable mass - no

Hernial orifices- normal

Free fluid - no

Bruits - no

Liver - not palpable 

Spleen - not palpable

Bowel sounds - heard and normal

Genitals - normal

Speculum examination- normal 

PV Examination-  normal

P/R Examination- normal




INVESTIGATIONS:

RAPID ANTIGEN TEST: NEGATIVE 



ABG:

On 17.06.2021 

pH - 7.26 

pCO2- 20 mm Hg

SpO2- 95.9%

Serum HCO3 = 11.5 mmol/L

HCO3(a) = 8.7 - 8.0




SERUM ELECTROLYTES:

On 17.06.2021

Na+ = 120mEq/L

K+ = 3.1mEq/L

Cl = 90 mEq/L


On 18.06.2021

On 19.06.2021



HEMOGRAM:



ULTRASOUND:



SERUM CREATININE:

4.7 mg/dl on 17.06.2021

On 18.06.2021


On 19.06.2021



CBP:

On 18.06.2021



On 16.06.2021




BLOOD UREA :  

157mg/dl on 17.06.2021

91 mg/dl on 18.06.2021 



132 mg/dl On 19.06.2021 






ECG:





X-RAY:











DIAGNOSIS:


ACUTE KIDNEY INJURY(AKI) SECONDARY TO UROSEPSIS ON CHRONIC KIDNEY DISEASE(CKD) SECONDARY TO HYPERTENSION NEPHROPATHY.




TREATMENT:

ON 17.06.2021

  1. IVF NS 10.9% AT 75ml/ hour
  2. INJ. PIPTAZ 2.25/IV/BD
  3. INJ. PANTOP 40mg/IV/OD
  4. TAB. NICARDIA 20mg/PO/OD
  5. TAB.NODOSIS 550mg/PO/BD
  6. TAB. OROFER- XT/PO/OD
  7. TAB. SHELCAL /PO/OD
  8. INJ ERYTHROPOIETIN 4000IU/SC WEEKLY ONCE 
  9. INJ. NaHCO3 100mEql/slow/IV/stat
Advice:
CBP
UREA
ELECTROLYTES
ABG
RTPCR


ON 18.06.2021

  1. IVF NS or RL 10.9% at 100ml/hour
  2. INJ. PIPTAZ 2.25gm/IV/BD
  3. INJ. PANTOP 40mg/IV/OD
  4. TAB. NICARDIA 20mg/PO/BD
  5. TAB. NODOSIS 550mg/PO/TID
  6. TAB. OROFER-XT/PO/BD
  7. TAB.SHELCAL /PO/OD
  8. INJ. ERYTHROPOIETIN 4000IU/SC WEEKLY ONCE
  9. INJ. NaHCO3 100mEql/slow IV/stat/
  10. INJ, TRAMADOL 1 amp in 100NS/IV/BD AFTER INJ. ZOFER 4CC/BD
  11. SYRUP. POTCHLOR 16ml/PO/TID
  12. INJ. LASIX 40mg/IV/BD

Advice:

ORTHOPAEDIC opinion for bilateral hip pain

Review USG for pyelonephritis 

ABG- R

ORTHOPAEDIC ADVICED TREATMENT:
  1. TAB. DOLO 650mg BD FOR 1 WEEK
  2. TAB. SHELCAL OD FOR 3 WEEKS
  3. TAB. LIMCEE TID FOR 10 DAYS


On 19.06.2021

  1. IVF.NS(0.9%) AT 75ml/hour if altered sensorium persists, 3%NaCl at 10ml/hour
  2. INJ. PIPTAZ 4.5gm/IV/stat after sending urine sample INJ. PIPTAZ 2.25gm/IV/BD
  3. INJ. PANTOP 40mg/IV/OD
  4. TAB. NICARDIA 20mg/PO/BD
  5. BP/PR/TEMPERATURE/ SpO2 HOURLY 
  6. STRICT I/O CHARTING
  7. TAB. NODOSIS 550mg/PO/BD
  8. TAB. OROFER- XT /PO/BD
  9. INJ. ERYTHROPOIETIN 4000IU/SC/ONCE WEEKLY
Advice:
Urine c/s - now
ECG
CXR-BEDSIDE
CBP,UREA,CREATININE,ELECTROLYTES AND ABG AT 6:00 am
RTPCR - TOMORROW 





Comments

Post a Comment

Popular posts from this blog

Internship

 MY INTERNSHIP JOURNEY IN GENERAL MEDICINE  I'm an intern, posted in general medicine department for 2 months including 2 weeks of psychiatry. First 2 weeks: Posted in Department of Psychiatry: Attended the OPD in department of psychiatry and observed various spectrum of psychiatric disorders in the patients. Studied symptomatology regarding various psychiatric disorder spectrums.  I got to know about the ICD-10 Classification of psychiatry disorders and also DSM Classification of diseases. Done night duties for observation of psychiatry patients of withdrawal syndromes. And learnt how to manage them. Attended the De addiction centre visits and observed the various types of medical, behavioural therapy going on there.  Learnt how to attend rounds for the patients and how to write repeats in the casesheets from post graduates. Typed, studied and submitted the discharge summaries of various patients under department of psychiatry. From this I learnt how to discharge a patient with pr
Read more

15 YEAR OLD MALE WITH ACUTE KIDNEY INJURY

Image
 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. 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 diagnosis and treatment plan Presenting complaints : A 15 yr old male ,studying 9 th class came to the casuality with C/O SOB( grade 2 - 3 ) since yesterday ,orthopnea +   HOPI : Pt was apparently asymptomatic 1 month back ,pt complains of
Read more

50 YEARS OLD MALE WITH WEAKNESS OF RIGHT UPPER LIKB AND LOWER LIMB

Image
 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 comments on comment box is welcome. 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 diagnosis and treatment plan. Presenting complaints: Patient came with the cheif complaints of weakness of right upper and lower limb since yesterday morning (04:00am) slurring of speech and deviation of mouth to lef
Read more