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.
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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
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
X-RAY:
DIAGNOSIS:
ACUTE KIDNEY INJURY(AKI) SECONDARY TO UROSEPSIS ON CHRONIC KIDNEY DISEASE(CKD) SECONDARY TO HYPERTENSION NEPHROPATHY.
TREATMENT:
ON 17.06.2021
- IVF NS 10.9% AT 75ml/ hour
- INJ. PIPTAZ 2.25/IV/BD
- INJ. PANTOP 40mg/IV/OD
- TAB. NICARDIA 20mg/PO/OD
- TAB.NODOSIS 550mg/PO/BD
- TAB. OROFER- XT/PO/OD
- TAB. SHELCAL /PO/OD
- INJ ERYTHROPOIETIN 4000IU/SC WEEKLY ONCE
- INJ. NaHCO3 100mEql/slow/IV/stat
ON 18.06.2021
- IVF NS or RL 10.9% at 100ml/hour
- INJ. PIPTAZ 2.25gm/IV/BD
- INJ. PANTOP 40mg/IV/OD
- TAB. NICARDIA 20mg/PO/BD
- TAB. NODOSIS 550mg/PO/TID
- TAB. OROFER-XT/PO/BD
- TAB.SHELCAL /PO/OD
- INJ. ERYTHROPOIETIN 4000IU/SC WEEKLY ONCE
- INJ. NaHCO3 100mEql/slow IV/stat/
- INJ, TRAMADOL 1 amp in 100NS/IV/BD AFTER INJ. ZOFER 4CC/BD
- SYRUP. POTCHLOR 16ml/PO/TID
- INJ. LASIX 40mg/IV/BD
Advice:
ORTHOPAEDIC opinion for bilateral hip pain
Review USG for pyelonephritis
ABG- R
- TAB. DOLO 650mg BD FOR 1 WEEK
- TAB. SHELCAL OD FOR 3 WEEKS
- TAB. LIMCEE TID FOR 10 DAYS
On 19.06.2021
- IVF.NS(0.9%) AT 75ml/hour if altered sensorium persists, 3%NaCl at 10ml/hour
- INJ. PIPTAZ 4.5gm/IV/stat after sending urine sample INJ. PIPTAZ 2.25gm/IV/BD
- INJ. PANTOP 40mg/IV/OD
- TAB. NICARDIA 20mg/PO/BD
- BP/PR/TEMPERATURE/ SpO2 HOURLY
- STRICT I/O CHARTING
- TAB. NODOSIS 550mg/PO/BD
- TAB. OROFER- XT /PO/BD
- INJ. ERYTHROPOIETIN 4000IU/SC/ONCE WEEKLY
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