36M AKI on CKD ; High Output HF(Anemia) ; HTN ; DM

 Case History and Clinical Findings

PATIENT CAME WITH C/O SEVERE PAIN IN THE RIGHT LEG WHILE WALKING SINCE 4 MONTHS AND FEVER SINCE 1 DAY.

HISTORY OF PRESENTING ILLNESS: PATIENT WAS APPARENTLY ASYMPTOMATIC 8 MONTHS BACK THEN HE HAD INJURY ON THE LEFT LOWER LIMB INCISION AND DRAINAGE AND DEBRIDEMENT WAS DONE OUTSIDE. SINCE 4 MONTHS, PATIENT HAD RIGHT SIDE THIGH PAIN DURING WALKING SINCE 4 MONTHS, GRADUALLY PROGRESSIVE AND WAS ON REGULAR FOLLOW UP IN OUTSIDE HOSPITAL.PATIENT HAD HIGH GRADE FEVER LAST NIGHT ASSOCIATED WITH CHILLS AND RIGORS CONTINUOUS WITH BODY PAINS AND WEAKNESS.

PAST HISTORY: PATIENT IS A KNOWN CASE OF TYPE 2 DIABETES MELLITUS SINCE 10 YEARS, USING MIXTARD 10U MORNING- 10U NIGHT

KNOWN CASE OF HYPERTENSION SINCE 5 MONTHS, USING NICARDIA 20 MG PO/OD. N/K/C/O ASTHMA,TB,EPILEPSY

PERSONAL HISTORY:

MODERATELY BUILT AND NOURISHED

APPETITE: NORMAL

SLEEP: DISTURBED DUE TO LEG PAIN

BOWEL AND BLADDER: REGULAR

NO KNOWN ALLERGIES

ADDICTIONS: 16 YEARS OF ALCOHOL HISTORY STARTE 3 YEARS BEFORE MARRIAGE CONSUMING AROUND 90 ML PER DAY

FAMILY HISTORY IS INSIGNIFICANT

GENRAL EXAMINATION:

THE PATIENT IS CONCIOUS, COHERENT AND COOPERATIVE, MODERATELY BUILT AND NOURISHED.

PALLOR IS PRESENT

EDEMA IS PRESENT

NO SIGNS OF ICTERUS CYANOSIS CLUBBING LYMPHADENOPATHY

VITALS:

TEMP: 101 F

BP: 140/100 MMHG

RR:24 CPM

HR:96 BPM

SPO2:100 ON 2 LIT 02

GRBS: 262 ON 19/4/23 AROUNG 6:45 PM

SYSTEMIC EXAMINATION:

CVS: S1, S2 HEARD, NO MURMURS

ABDOMEN :- SOFT ,NON TENDER

RS: BAE+, NVBS

CNS: HIGHER MENTAL FUNCTIONS INTACT, NO FOCAL NEUROLOGICAL DEFICIT

SURGERY REFERRAL DONE ON 20/4/23

ADVICE: CONSIDER ANTIBIOTICS- T. METROGYL 400 MG PO/TID

LIMB ELEVATION, MGSO4 DRESSINGS

ORTHOPAEDICS REFERRAL DONE ON 20/4/23

ADVICE: 1) INJ CLINDAMYCIN 600 MG IV/TID X 5 DAYS

2) TAB XYKAA 650 MG PO/TID X 5 DAYS

3) TAB PAN 40 MG PO/OD X 5 DAYS

4) RIGHT LOWER LIMB ELEVATION

5) TAB. CHYMEROL FORTE PO/BD X 3 DAYS

NEPHROLOGY REFERRAL DONE ON 20/4/23

ADVICE: 1) I.V FLUIDS NS @ 75 ML/HR

2) INJ. LASIX 40 MG IV/BD

3) STRICT INPUT, OUTPUT CHARTING

OPHTALMOLOGY REFERRAL DONE ON 20/4/23

IMPRESSION: ON FUNDUS EXAMINATION, NO CHANGES OF DIABETIC OR HYPERTENSIVE RETINOPATHY NOTED.

1 PRBC TRANSFUSION DONE ON 21/4/23


Provisional Diagnosis:-

PRE RENAL AKI ON CKD SECONDARY TO ? MYOSITIS OF RIGHT LOWER LIMB

HIGH OUTPUT HEART FAILURE SECONDARY TO ANEMIA


Investigation:-

2D ECHO DONE ON 20/4/23

MILD TR+ WITH ?PAH, TRIVIAL MR+, NO AR, NO RWMA, NO AS/MS, GOOD LV SYSTOLIC FUNCTION, NO DIASTOLIC DYSFUNCTION, NO LV CLOT

USG ABDOMEN ON 19/4/23

IMPRESSION: RAISED ECHOGENECITY OF B/L KIDNEYS, GRADE 1 FATTY LIVER WITH HEPATOMEGALY

ARTERIAL AND VENOUS DOPPLER OF B/L LOWER LIMBS DONE ON 21/4/23

IMPRESSION: ALL EXAMINED ARTERIES SHOW NORMAL TRIPHASIC WAVEFORM, NO E/O DVT, ATHEROSCLEROTIC CHANGES IN ALL EXAMINED ARTERIES, NO STENOSIS

SUBCUTNEOUS EDEMA NOTED IN RIGHT LOWER LIMB BELOW KNEE, SUBCUTANEOUS AND SOFT TISSUE EDEMATOUS CHANGES NOTED ALONG LATERAL ASPECT OF RIGHT THIGH

USG ABDOMEN ON 21/4/23

IMPRESSION:RAISED ECHOGENECITY OF B/L KIDNEYS, GRADE 1 FATTY LIVER WITH HEPATOMEGALY, MINIMAL ASCITES, RIGHT MILD PLEURAL EFFUSION.

RAISED ECHOGENECITY OF B/L KIDNEYS, GRADE 1 FATTY LIVER WITH HEPATOMEGALY

HEMOGRAM ON 19/4/23

HB: 6.7 MG/DL

TLC: 6500 CELLS/CU.MM

PLTS: 1.30 LAKH/CU.MM

RBC: 2.43 MILLION/CU.MM

PCV:21.6%

HEMOGRAM ON 22/4/23

HB: 7.7 MG/DL

TLC: 11000 CELLS/CU.MM

PLTS: 1.89 LAKH/CU.MM

PCV:25.3%

HEMOGRAM ON 23/4/23

HB: 7.1 MG/DL

TLC: 7000 CELLS/CU.MM

PLTS: 1.90 LAKH/CU.MM

PCV:23.7%

HEMOGRAM ON 24/4/23

HB: 6.9 MG/DL

TLC: 9100 CELLS/CU.MM

PLTS: 2.1 LAKH/CU.MM

PCV:22.9%

Treatment Given(Enter only Generic Name)

1) IV FLUIDS NS @ 30 ML/HR

2) INJ. CLINDAMYCIN 600 MG IV/TID

3)INJ. LASIX 40 MG IV/TID

4) INJ. TRAMADOL IN 100 ML NS IV/BD

5) INJ. HAI SC/TID AND NPH SC/BD

6) TAB. PCM 650 MG PO/QID

7) TAB. NICARDIA 10MG PO/QID

8) NEB SALBUTAMOL 4TH HOURLY

9) TAB. NODOSIS 500 MG PO/BD

10) NEB WITH IPRAVENT 4 TH HOURLY, BUDECORT 6TH HOURLY

11) INJ. ZOFER 4 MG PO/BD

12) INJ. NEOMOL 1 GM IV/SOS

13) INJ BICARB 50 MEQ IV/STAT

14) INJ BICARB 100 MEQ IN 500 ML NS IV/STAT

Advice at Discharge

TAB. PCM 650 MG PO/QID

TAB. NICARDIA 10MG PO/QID

TAB. NODOSIS 500 MG PO/BD

INJ. HAI SC/TID

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