35 year female with AKI on CKD

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 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.

CASE SCENARIO : 

A 35 year female,  came to casualty with  c/o bilateral pedal edema since 20 days,

Decreased urine output since 20 days,

Facial puffiness , shortness of breath ( a/w orthopnea and PND ) 

H/O fever spike +, 10 days back, not associated with chills and rigor, subsided on taking medication.

C/o cough with expectoration, yellowish in colour,

Pt was apparently asymptomatic 2 months back then she developed chest pain for which she visited local hospital in miryalaguda , on evaluation she was diagnosed to have chronic kidney disease and low hemoglobin, 2PRBC Transfusions were done 

After PRBC transfusion she developed b/l pedal edema, which subsided on medication.,

 20 days back she developed b/l pedal edema, reduced urine output, sob a/w orthopnea, and PND, and facial puffiness. 

10 days back she developed fever a/w chills and rigor, which subsided on medication.

1 PRBC transfusion done in Nalgonda hospital yesterday.

K/c/o HTN since 3 year's

Not a k/c/o DM, asthma, TB.

O/E : 

pt is c/c/c,

Pallor - present

Icterus - absent

Cyanosis - absent

Clubbing - absent

Lymphadenopathy - absent

Pedal edema - b/l present

Vitals:

Afebrile

Bp: 170/100 mm hg

PR: 99 bpm

RR: 22 cpm

SpO2: 87% @RA

CVS: S1,S2 +

RS: BAE+

P/A: SOFT, NON TENDER

CNS: NAD 


Outside reports on 30/11/21:











On 02/12/21:



On 17/12/21:



PROVISIONAL DIAGNOSIS :
 AKI ON CKD (stage v), with egfr: 5ml/hr, with metabolic acidosis ( resolving ), with b/l pleural effusion with k/c/o HTN since 10 years.

TREATMENT :

1. Head end elevation upto 30'

2. O2 supplementation if SpO2 < 90%

3. Inj. Lasix 40mg iv tid 

4. Inj. PIPTAZ 2.25gms IV BD ( D1)

5. TAB. NICARDIA 10MG PO BD 

6. TAB. NODOSIS 550MG PO BD 

7. TAB. SHELCAL 500 MG PO OD 

8. NEB. WITH SALBUTAMOL 2 RESIPULES / 4TH HRLY,

9. INJ. ERYTHROPOIETIN 4000 IU S/C WEEKLY ONCE 

10. SYP. ASCORYL PO TID 

11. HRLY VITALS MONITORING.

Day 2 :

Sob reduced

Pedal edema reduced



ON EXAMINATION :

Pt is c/c/c

Pallor +



B/l Pedal edema +



No icterus, cyanosis, clubbing, lymphadenopathy

Afebrile
Bp: 160/80 mm hg
PR: 88 bpm
RR: 22 cpm
SpO2 : 92% @RA 
CVS: S1,S2 +
RS: BAE+, decreased breathsounds in b/l ISA, MSA
P/A: SOFT, NON TENDER
CNS: NAD 


A: AKI ON CKD (stage v), with egfr: 5ml/hr, with metabolic acidosis ( resolving ), with b/l pleural effusion with k/c/o HTN since 10 years.

Treatment :

1. Head end elevation upto 30'

2. O2 supplementation if SpO2 < 90%

3. Inj. Lasix 40mg iv tid 

4. Inj. PIPTAZ 2.25gms IV BD ( D2)

5. TAB. NICARDIA 10MG PO BD 

6. TAB. NODOSIS 550MG PO BD 

7. Tab. Orofer XT PO/OD

8. TAB. SHELCAL 500 MG PO OD 

9. NEB. WITH SALBUTAMOL 2 RESIPULES / 4TH HRLY,

10. INJ. ERYTHROPOIETIN 4000 IU S/C WEEKLY ONCE 

11. Inj. Iron sucrose 1 amp in 100ml NS

12. SYP. ASCORYL PO TID 

13. HRLY VITALS MONITORING.

On 18/12/21


On 19-12-2021


On 20-12-2021


Sob reduced

Pedal edema reduced

On examination :

Pt is c/c/c

Pallor +

B/l Pedal edema +

No icterus, cyanosis, clubbing, lymphadenopathy

Afebrile

Bp: 160/80 mm hg

PR: 88 bpm

RR: 22 cpm

SpO2: 92% @RA

CVS: S1,S2 +

RS: BAE+, decreased breathsounds in b/l ISA, MSA

P/A: SOFT, NON TENDER

CNS: NAD 

A: AKI ON CKD (stage v), with egfr: 5ml/hr, with metabolic acidosis ( resolving ), with b/l pleural effusion with k/c/o HTN since 10 months

P:

1. Head end elevation upto 30'

2 .Inj. Lasix 40mg iv tid 

3. TAB. NICARDIA 10MG PO BD 

4. TAB. NODOSIS 550MG PO BD 

5. Tab. Orofer XT PO/OD

6. TAB. SHELCAL 500 MG PO OD 

7. NEB. WITH SALBUTAMOL 2 RESIPULES / 4TH HRLY,

8. INJ. ERYTHROPOIETIN 4000 IU S/C WEEKLY ONCE 

9. Inj. Iron sucrose 1 amp in 100ml NS

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