Final practicals-Long case-1802102002
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A 65 year old male patient toddy tree climber by occupation came to our hospital on 2nd February with chief complaints of absence of urine output (anuria)since 1 day and shortness of breath since 1 day.
History of present illness:-
Patient was apparently asymptomatic 15 years back ,then he suddenly fell from toddy tree while climbing ,then he had fracture of femur for which open reduction and internal fixation(ORIF) was done.
Patient had got flexion fixed deformities since 7 years. Patient is unable lie down flat ,he is unable to put his neck on pillow since 7 years.
Patient stays at home and stopped drinking bore water since 10 years.
Now since 1 day there was sudden onset of shortness of breath and anuria for which he came to our hospital.
Past history:-
Patient is a known case of hypertension. Not a known case of diabetes mellitus, Tb,asthma,epilepsy.
Patient had h/o renal calculi 20 years back.
As told by the patient and his attenders
First he had h/o fall from tree 15 yrs back,had fracture of femur ,ORIF was done. He used to walk with support for few months
Then after 5 years he had h/o fall ,had fracture of tibia, no treatment was done
Then again he had h/o fall at his home, ?fracture of hip
From then he was unable to walk even with support.
Personal history:-
Patient has normal eating habit with mixed diet .
Loss of apetite.
He had habits of alcohol consumption occasionally and also habit of smoking.
Family history :-
No significant family history.
Treatment history:-
On regular medication for hypertension Tab AMLONG 5mg OD
Surgery done for renal Calculi.
General examination:-
Patient was conscious,coherent,cooperative
and well oriented to time,place and person.
Signs of pallor and pedal edema are present .
No cyanosis,jaundice,clubbing.
Vitals:-
TEMPERATURE - 98.6 F
PULSE - 100 BPM
RR - 16 CPM
BP - 160/90 MMHG
Spo2 - 98 % @ ROOM AIR
GRBS: 106MG%
CVS - S1S2 HEARD , NO MURMURS.
CNS - INTACT.
RS :- DYSPNOEA PRESENT ; BREATH SOUNDS - VESICULAR .
PER ABDOMEN : SOFT, NONTENDER
INVESTIGATIONS:-
Complete urine examination:-
Blood urea:-117mg/dl (normal-17-50)
Serum creatinine:-5.8mg/dl (normal-0.8-1.3)
Xray spine lateral
Chest XRay PA
2d ECHO:-
Ultrasound:-
Provisional diagnosis:-
Post renal AKI secondary to B/L Ureteric Calculi and Bladder Calculi - Moderate Hydrouretero Nephrosis.
Fixed flexion deformities at knee and hip joint and ankylosing spondylitis.
Treatment plan:-
IV FLUIDS 2 U NS & 2 U RL @ 100 ML / HR
INJ LASIX 40 MG IV / BD
INJ PAN 40 MG IV / OD
NEBULIZATION WITH DUOLIN & BUDECORCT 8TH HOURLY
DAY - 2 :-
S : ONE SESSION OF HAEMODIALYSIS WAS YESTERDAY (INDICATION OF DIALYSIS - ANURIA SINCE 1 DAY)
0 : TEMP - AFEBRILE
BP - 130/90 MMHG
PULSE -86 BPM
RR - 20 CPM
SPO2 98% @ RA
CVS -S1S2+, NO MURMURS
RS - BAE +
PA - SOFT, NON TENDER
A : AKI ON CKD??? WITH LEFT RENAL CALCULUS SIZE 4MM B/L HYDRONEPHROSIS
P
1) Inj. AUGMENTIN 500mg / IV/BP
2) Inj. LASIX 40mg/IV/BD
3)ORAL FLUIDS ~2L.
4) Inj. PAN 40mg /IV/OD
5) Neb with DUOLIN & Budecort 8th hourly
6) Tab. AMLONG 5mg po/OD
DAY 3 :-
S: URINE OUTPUT INCREASED-1700ml
O: ONE SESSION OF HEMODIALYSIS DONE ON 3/02/2022
TEMP - AFEBRILE
BP - 130/90 MMHG
PULSE-82 BPM
RR - 20 CPM
SPO2 - 98% @ RA
CVS - S1S2+, NO MURMURS
RS - BAE +
PA - SOFT, NON TENDER
A: AKI ON CKD??? SECONDARY TO BPH ?, URETHRAL STRICTURE? WITH LEFT RENAL CALCULUS SIZE 4MM B/L HYDRONEPHROSIS
P:
1) Inj. Meropenem 500mg / IV/BD
2) Inj. LASIX 40mg/IV/BD
3) ORAL FLUIDS ~2L.
4) Inj. PAN 40mg /IV/OD
5) Neb with DUOLIN & Budecort 8th hourly
6) Tab. AMLONG 5mg po/OD
DAY - 4
S:Urine output has improved.
O:Hemodialysis was done (total 2 sessions of dialysis was done)
TEMP - AFEBRILE
BP - 130/70 MMHG
PULSE - 96 BPM
CVS -S1S2+, NO MURMURS
RS - BAE +
PA - SOFT, NON TENDER
A : PostRenal AKI Secondary to B/L Ureteric Calculi
- Moderate Hydrouretero Nephrosis with left Renal Calculi
P :
1) Inj. Meropenem 500mg / IV/BD
2) Inj. LASIX 40mg/IV/BD
3) ORAL FLUIDS ~2L.
4) Inj. PAN 40mg /IV/OD
5) Neb with DUOLIN & Budecort 8th hourly
6) Tab. AMLONG 5mg po/OD
DAY - 5 :-
S: Urineoutput Improved , Patient complainting Of Loss Of Appetite , No Fever Spikes
0 : HAEMODIALYSIS (Total - 2 Dialysis ) .
Output - 1800ml
Input - 1600ml
TEMP - AFEBRILE
BP - 130/80 MMHG
PULSE - 96 BPM
CVS -S1S2+, NO MURMURS
RS - BAE +
PA - SOFT, NON TENDER
A : PostRenal AKI Secondary to B/L Ureteric Calculi and Bladder Calculi
- Moderate Hydrouretero Nephrosis with left Renal Calculi
P:
1) Inj. Meropenem 500mg / IV/B
2) Inj. LASIX 40mg/IV/BD
3 )ORAL FLUIDS ~2L.
4) Tab. AMLONG 5mg po/OD
