Acute kidney injury 2° to urosepsis

March 07, 2022

This is 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .

B.Aishwarya laxmi

Rollno;152

9th semester

 

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 diagnosis and treatment plan

( All the information have been collabated from patient).

Case discussion;

Following is the view of my case

60 year old female daily wage labourer by occupation resident of chandoor came to casuality on 4/03/22.

Chief complaints;

Acute retention of urine since 5 days

History of present illness;

The patient was apparently asymptomatic 20 days back .she visited her younger sister house for attending some function there she had a fever which was low grade associated with chills and rigor.which was on and off.increased during night time.  Associated with cold she visited local rmp fever was relieved on medication .after 10 days she had decreased urine out put and not passed stools for 2 days and had 1 syncope attack. She felt on the ground which was observed by her relatives

* Suprapubic bulge was noted  and she had pain over suprapubic region. her son taken her to local hospital for examination and Foley's catheter was kept and she passed approximately about 1 litre of urine .

* Their they told that infection is there and referred to our hospital.

No c/o chest pain, sob, palpitations

Past history:

She is not a k/c/o diabetes, hypertension,asthma,tb, epilepsy cva,cad

Family history ; insignificant

Personal history ;

Appetite : decreased

Diet ; mixed

Bowel : regular

Bladder : decreased urine output

Sleep : adequate

Addictions : occasional toddy drinker

General examination;

The patient is conscious, coherent, cooperative and moderately built and moderately nourished.

Pallor :  present

Icterus : absent

Cyanosis,; absent

Clubbing: absent

Edema : absent 

No generalized lymphadenopathy

Jvp raised

Vitals ;

Temperature; 98.3° f

Pulse rate: 90bpm

Blood pressure; 100/70 mmHg

Respiratory rate : 22cpm

Spo2 : 98%@room air

GRBS: 112mg/dl

Systemic examination;

Per abdomen examination;

Inspection;

Shape of abdomen : scaphoid, suprapubic bulge was noted

Umbilicus ; central

No visible pulsations,engorged viene,no visible peristalsis

Movements equal on respiration

Skin over abdomen normal

Palpation;

Tenderness in suprapubic region ,

No loacl rise of temperature

No organomegaly 

Percussion:

Resonant note heared

Auscultation; bowel sounds were heared

Respiratory system;

Bilateral air entry present,trachea is in central position.

Normal vesicular breath sounds were heared

Cardiovascular system;

S1,S2 heart sounds heared.

Central nervous system;

Higher mental functions;

Leave of consciousness ; normal

Speech: normal

No meningeal signs

Cranial nerve s : intact

Provisional diagnosis;

Acute kidney injury secondary to  urosepsis

( Intrinsic)

Investigations;

On 5/3/22;

Serum electrolytes; 

Sodium- 139

Potassium- 5.2

Chloride- 99

Serum creatinine - 8.0- 6.1

Serum urea- 333- 260

TOTAL bilirubin: 1.8

Direct bilirubin: 0.83

AST : 26

ALT : 28

ALP ; 902

Total protein: 4.9

Albumin,; 2.2

On 7/3/22

On 6/3/22

On 7/3/22

On 6/3/22

Treatment;

On 4/3/22

1) inj.piptaz 4.5gm iv start 

2)Inj piptaz 2.25gm/iv/qid

3) Inj pan 40mg iv od

4)iv fluids NS/RL @100ml/,hour

5) Inj zofer 4mg iv od

6) Inj optineuron 1amp iv 500ml NS od

7) tab Nodosis500mg po od

8) Inj lasix40 mg iv tid

On7/3/22 ; on examination 

Pt is conscious coherent, cooperative

PR: 80bpm

BP: 130/90mmhg

1) inj.piptaz 4.5gm iv start 

2)Inj piptaz 2.25gm/iv/qid

3) Inj pan 40mg iv od

4)iv fluids NS/RL @100ml/,hour

5) Inj zofer 4mg iv od

6) Inj optineuron 1amp iv 500ml NS od

7) tab Nodosis500mg po od

8) Inj lasix40 mg iv tid

9)tab Tamsulosin0.4mg Hs

On8/3/22;

Pt is conscious coherent, cooperative

PR: 80bpm

BP: 130/90mmhg

1)Inj piptaz 2.25gm/iv/qid

2) Inj pan 40mg iv od

5)iv fluids NS/RL @100ml/,hour

6) Inj zofer 4mg iv od

7) Inj optineuron 1amp iv 500ml NS od

8) tab Nodosis500mg po od

9) Inj lasix40 mg iv tid

10)tab Tamsulosin0.4mg Hs

11)syp cypon 10ml TID