Aki on ckd

 


This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome.


A 65 year old patient is a    by occupation, resident of     has to come to the casualty with 

CHIEF COMPLAINTS of :


  • C/o   B/L  lower limb pain and swelling since 10 days
  • C/o   B/L loin pain since 10 days
  • C/o   fever with chills since 8 days
  • C/o   B/L pain in inguinal region since 5 days
  • C/o   loose stools since 3 days

HISTORY OF PRESENT ILLNESS:


Patient was apparently asymptomatic 10 days back, then developed B/L pedal edema-pitting type associated with pain and redness with local rise in temperature. He also had B/L loin pain 10 days back. Later he had complains of intermittent fever associated with chill, no diurnal variation since 5 days. He c/o B/L pain inguinal region. C/o loose stools since 3 days, watery and not associated with blood. 

HISTORY OF PAST ILLNESS:


  • H/o  blood in urine 1 year back, resolved after taking medications
  • H/o trauma to back after a fall which was managed conservatively
  • N/K/C/O  HTN, DM, TB, Asthma, Epilepsy, CAD, CVA.

PERSONAL HISTORY:



  • Marital Status: Married
  • Occupation: Farmer
  • Appetite: Normal
  • Diet: Mixed
  • Bowel: Normal
  • Micturition: Normal
  • Any known allergies: No
  • Addictions: Consumes alcohol occasionally, smokes sutta

FAMILY HISTORY:


Insignificant family history

PHYSICAL EXAMINATION:

A) GENERAL: 


  •  Patient is conscious, coherent, cooperative
  • Pallor- No
  • Icterus- No
  • Cyanosis- No
  • Clubbing- No
  • Lymphadenopathy- No
  • Pedal edema- Present (grade- 2)



  • Malnutrition- No 
  • Temperature- Afebrile on touch
  • Pulse rate- 84 bpm
  • Respiratory rate-18 cpm 
  • BP:110/70 mmHg
  • Spo2: 98%
  • GRBS:83mg/dl

SYSTEMIC EXAMINATION:


B) CVS:

  • Thrills- absent
  • Cardiac sounds- S1 S2 heard
  • Cardiac murmurs- absent

C) RESPIRATORY SYSTEM:

  • Dyspnoea- absent
  • Wheeze- absent
  • Position of trachea- central
  • Breath sounds- NVBS heard

D) ABDOMEN:

   1) INSPECTION:

  • Shape- Scaphoid
  • Flanks- free
  • Umbilicus- centrally located, inverted, no nodules 
  • Skin- normal, scars absent 
  • Dilated veins- absent  

  2) PALPATION:

  • soft, non-tender, no organomegaly
  •   3) AUSCULTATION:
  • Bowel sounds- 4-5/min 

E) CNS:

  • Level of consciousness- conscious
  • Speech- normal

PROVISIONAL DIAGNOSIS:

        ACUTE KIDNEY INJURY  on   CKD


INVESTIGATIONS:

  •  Hemogram
  •  CUE
  •  RFT
  •  LFT
  •  Serology
  •  ECG
  • Chest X-ray
  • USG Abdomen

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TREATMENT:



11/4/23  7:00 a.m 


O- O/E  Pt is c/c/c

             Temp- Afebrile on touch

             PR- 84 bpm

             RR- 18 cpm

             BP- 110/70 mmHg

             SpO2- 98% 

             CVS- S1 S2 heard

             RS- B/L Air entry +

                    NVBS heard

             P/A- soft, non-tender, no organomegaly

             CNS- NFND


A- AKI on CKD


P- 1) I.V  Fluids NS @ 100 ml/hr

     2) Inj. Lasix 40 mg  IV/BD

     3) Inj. Piptaz 4.5 gm  IV/stat




12/4/23    8:00 a.m


S- No fever spikes


O- O/E   Pt is c/c/c

              Temp- Afebrile on touch

              PR- 86 bpm

              RR- 20 cpm

              BP- 110/70 mmHg

              SpO2- 95%

              GRBS- 98 mg/dl

              I/O- 800/450 ml

              CVS- S1 S2 heard

              RS- B/L Air entry +

                     NVBS heard

              CNS- NFND

              P/A- soft, non-tender, no organomegaly



A-  AKI on CKD


P-  1) I.V  Fluids 20 NS @ 100ml/hr

      2) Inj. Piptaz 2.25 gm  IV/TID

          8am------2pm------8pm

      3) Inj. Metrogyl 500 mg  IV/TID

           8am------2pm------8pm

      4) Inj. Pantop 40 mg  IV/OD                 

           7am--------(before breakfast)

      5) Inj. Lasix 40 mg  IV/BD

          (only if SBP > 110 mmHg)

      6) Inj. PCM 1000 mg  IV SOS

          (if temp > 101F)

      7) Tab. PCM 650 mg  PO SOS

      8) Tab. Ultracet 1/2 tab  PO SOS 

      9) Temp. monitoring 4th hourly

    10) PR, RR, BP, SpO2, GRBS  monitoring 4th hourly

    11) Strict I/O charting



13/4/23   8:00 a.m


O- O/E  Pt is c/c/c

             Temp- Afebrile on touch

             PR- 82 bpm

             RR- 18 cpm

             BP- 100/60 mmHg

             SpO2- 92%

             GRBS- 136 mg/dl

             I/O- 1350ml(output)

             CVS-S1 S2 heard

             RS- BAE +

             P/A- soft, non-tender, no organomegaly

             CNS- NFND


A- AKI on CKD



P-  1) I.V Fluids 20 NS @100 ml/hr             

      2) Inj. Piptaz 2.25 mg  IV/TID

      3) Inj. Metrogyl 500 mg  IV/TID

      4) Inj. Pan 40 mg  IV/TID  (before breakfast)

      5) Inj. Lasix 40 mg  IV/BD

           (if SBP > 110 mmHg)

      6) Inj. PCM 1 gm  IV/SOS

           (if temp > 101F)

      7) Tab. PCM 650 mg  PO/SOS

      8) Tab. Ultracet 1/2 tab PO/SOS

      9) Temp monitoring 4th hourly

    10) PR, RR, BP, SpO2, GRBS monitoring 4th hourly 

    11) Strict I/O charting

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