65/M WITH RENAL AKI SECONDARY TO UTI

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I have 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.

CASE SCENARIO

A 65 yr old male came to the opd with C/C of 

Generalized weakness and not Able to walk since 2 weeks

Fever since 1 week

Loss of appetite and nausea since 1 week

B/L pedal oedema since 1 week

Decreased urine output since 1 week

Burning micturition since 1 week

Drowsiness since 1 day

HISTORY OF PRESENT ILLNESS

       Patient was apparently alright 1 week back then he had 

Insidious onset of fever, low grade, intermittent, not associated with chills and rigors. Relived on taking medication.

Pedal edema - insidious in onset, gradually progressive from foot to knee and is pitting type.

No PND and orthopnea

Fever is associated with loss of appetite, nausea, generalised weakness and unable to walk

There is decreased in the urine output and burning micturition since 1 week

From 1day the patient is drowsy and excessively sleepy

PAST HISTORY

      Not a known case of diabetes, HTN, CAD, asthma and TB

PERSONAL HISTORY

Occupation - used to work as labour in crop fields.

Appetite - Decreased

Diet - mixed

Bowel movements - regular 

Micturution - decreased

Alcohol - Regular - takes 180ml/day since 3years

FAMILY HISTORY

       No significant family history

GENERAL EXAMINATION

No pallor 

No icterus 

No cyanosis and clubbing

No lymphadenopathy 

Edema - pedal and pitting type

Vitals

Temperature - 99.4°F

PR - 103bpm

RR - 28cpm

BP - 130/70mm Hg

SpO2 - 95%

GRBS - 86 mg%

SYSTEMIC EXAMINATION

CVS:S1 S2 HEARD, NO MURMURS.

RS: NVBS heard, BAE +, TRACHEA CENTRAL.

P/A : SOFT, NON TENDER, NON DISTENDED.

CNS: CONSCIOUS, NO SIGNS OF MENINGEAL IRRITATION.

REFLEXES.

                                      RT. LT.

                   BICEPS.       + +

                   TRICEPS.      + +

                   SUPINATOR. + +

                   KNEE              + +

                   ANKL            + +

                   PLANTAR: FLEXOR.

PROVISIONAL DIAGNOSIS

    UTI WITH AKI WITH HYPONATREMIA

INVESTIGATIONS 

1) ECG 

2) Ultrasound

3) Chest X - ray

4) ABG

5) RFT

6) Serology 

7) Haemogram

8) 2D ECHO

TREATMENT

• FOSFOMYCIN sachet - 3mg in 1glass of water/ stat

• Tab DOLO 650mg PO/ TID

• Tab NODOSIS PO/BD

• Strict I/O charting

• Condome Catheterization

• Inj LASIX 40mg IV/BD if SBP > or = 110mmHg

• IVF 20NS @75ml/hr

• Temperature charting 4th hourly

• GRBS charting 8th hourly

• BP / PR / RR / Spo2 charting 2nd hourly

DAY 2 

 SUBJECTIVE:

Altere sensorium

OBJECTIVE

Temperature-97 F

Bp-120/60 mmhg

PR- 90bpm

RR -11 cpm

GRBS - 90 gm/dl

ASSESSMENT-

RENAL AKI WITH UREMIC ENCEPHALOPATHY

PLAN OF CARE- 

1. High flow O2 @15lit/min

2. IVF- NS@ 100ml/hr, RL@75ml/hr

3. Inj. Piptaz 2.25 gm/IV/TID

4. Tab. Nodosis 500mg/PO/BD

5. RT feeds 200ml milk protein powder (2nd hourly, 100ml water/2nd hourly)

6. Inj.Metrogyl 100ml/IV/TID

7. Inj. Pantop 40mg/IV/OD

1) Central line placed with consent taken

    Complication: Hemothorax

    --- X ray

     

ICD placed 

Xray post icd 

 Day3

SUBJECTIVE:

Fever spike

Stools not passed

Drowsy but arousable

OBJECTIVE

Temperature-101 F

Bp-130/80 mmhg

PR- 90bpm

RR -11 cpm

GRBS - 101 gm/dl

ASSESSMENT-

RENAL AKI WITH UREMIC ENCEPHALOPATHY

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

PLAN OF CARE- 

1. High flow O2 @15lit/min

2. IVF- NS@ 100ml/hr, RL@75ml/hr

3. Inj. Piptaz 2.25 gm/IV/TID

4. Tab. Nodosis 500mg/PO/BD

5. RT feeds 200ml milk protein powder (2nd hourly, 100ml water/2nd hourly)

6. Inj.Metrogyl 100ml/IV/TID

7. Inj. Pantop 40mg/IV/OD

8. Tab. Shelcal 500 mg/PO/BD

9. TAB. Dolo 650 PO/SOS

10. TAB. Lasix 40mg/PO/BD

11. NEB WITH DUOLIN/IN/TID, BUDECORT/IN/BD

12. Dialysis done(along with Blood Transfusion)(1 unit)

Urine culture on mc conkey agar 

       1) lactose fermenting colonies formed(pink)

       2) Indole(+ve), citrate(-ve), urease(+ve), 

       3) Triple sugar iron -- A/A WITH GAS

       4) Gram Stain -- Gram -ve bacilli

F/S/O:- E-coli

Day 4

SUBJECTIVE:

PAIN AT DRAIN SITE

OBJECTIVE

Temperature-101 F

Bp-150/80 mmhg

PR- 86bpm

RR -16 cpm

GRBS - 101 gm/dl

ASSESSMENT-

RENAL AKI WITH UREMIC ENCEPHALOPATHY

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

PLAN OF CARE- 

1. High flow O2 @15lit/min

2. IVF- NS@ 100ml/hr, RL@75ml/hr

3. Inj. Piptaz 2.25 gm/IV/TID

4. Tab. Nodosis 500mg/PO/BD

5. RT feeds 200ml milk protein powder (2nd hourly, 100ml water/2nd hourly)

6. Inj.Metrogyl 100ml/IV/TID

7. Inj. Pantop 40mg/IV/OD

8. Tab. Shelcal 500 mg/PO/BD

9. TAB. Dolo 650 PO/SOS

10. TAB. Lasix 40mg/PO/BD

11. NEB WITH DUOLIN/IN/TID, BUDECORT/IN/BD

12. Syp. LACTULOSE 10ml/RT/HS

13. 2nd dialysis done (Along with Blood Transfusion)(1 unit)

Day 5

SUBJECTIVE:

PAIN AT DRAIN SITE

OBJECTIVE

Temperature-101 F

Bp-150/80 mmhg

PR- 86bpm

RR -16 cpm

GRBS - 101 gm/dl

ASSESSMENT-

RENAL AKI WITH UREMIC ENCEPHALOPATHY

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

PLAN OF CARE- 

1. High flow O2 @15lit/min

2. IVF- NS@ 100ml/hr, RL@75ml/hr

3. Inj. Piptaz 2.25 gm/IV/TID

4. Tab. Nodosis 500mg/PO/BD

5. RT feeds 200ml milk protein powder (2nd hourly, 100ml water/2nd hourly)

6. Inj.Metrogyl 100ml/IV/TID

7. Inj. Pantop 40mg/IV/OD

8. Tab. Shelcal 500 mg/PO/BD

9. TAB. Dolo 650 PO/SOS

10. TAB. Lasix 40mg/PO/BD

11. NEB WITH DUOLIN/IN/TID, BUDECORT/IN/BD

12. Syp. LACTULOSE 10ml/RT/HS

Day 6

SUBJECTIVE:

PAIN AT DRAIN SITE

OBJECTIVE

Temperature-101 F

Bp-150/80 mmhg

PR- 86bpm

RR -16 cpm

GRBS - 101 gm/dl

ASSESSMENT-

RENAL AKI WITH UREMIC ENCEPHALOPATHY

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

PLAN OF CARE- 

1. High flow O2 @15lit/min

2. IVF- NS@ 100ml/hr, RL@75ml/hr

3. Inj. Piptaz 2.25 gm/IV/TID

4. Tab. Nodosis 500mg/PO/BD

5. RT feeds 200ml milk protein powder (2nd hourly, 100ml water/2nd hourly)

6. Inj.Metrogyl 100ml/IV/TID

7. Inj. Pantop 40mg/IV/OD

8. Tab. Shelcal 500 mg/PO/BD

9. TAB. Dolo 650 PO/SOS

10. TAB. Lasix 40mg/PO/BD

11. NEB WITH DUOLIN/IN/TID, BUDECORT/IN/BD

12. Syp. LACTULOSE 10ml/RT/HS

13.3rd dialysis done (along with 1 unit of blood transfusion)

Day 7-

SOAP NOTES 

 A 65 yr old man with  AKI SECONDARY TO UTI 

Subjective : 

 Pt complaints of burning micturition 

Objective :

 Temp:98

 PR:94 

 RR: 22

 BP: 120/70mmhg 

 Grbs :100 

Assessment-

RENAL AKI SECONDARY TO UTI (ECOLI sps) 

WITH IATROGENIC HEMOTHORAX (SECONDARY TO CENTRAL LINE INSERTION) 

WITH ANEMIA SECONDARY TO BLOOD LOSS 

Plan of treatment - 

1) ORAL FEEDS 

2. inj PIPTAZ 2.25gm /iv /tid 

3. Inj METROGYL 100ml / iv/tid 

4. Inj PAN 40mg /iv / od 

5. TAB LASIX 40mg /po/ od 

6. Tab NODOSIS 500 mg /po /od 

7. Tab DOLO 650mg /po/sos 

8. NEBULISATION WITH DUOLIN /tid.                   BUDECORT /bd 

9. SYP LACTULISE 10ml /po/ HIS

Day 8

SOAP NOTES 

 A 65 yr old man with  AKI SECONDARY TO UTI 

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

Subjective : 

 Pt complaints of burning micturition

Objective :

 Temp:98

 PR:94 

 RR: 22

 BP: 120/70mmhg 

 Grbs :100 

Assessment-

RENAL AKI SECONDARY TO UTI (ECOLI sps) 

WITH IATROGENIC HEMOTHORAX (SECONDARY TO CENTRAL LINE INSERTION) 

WITH ANEMIA SECONDARY TO BLOOD LOSS 

Plan of treatment - 

1.ORAL FEEDS

2. Inj PAN 40mg /iv / od 

3. TAB LASIX 40mg /po/ od 

4. Tab NODOSIS 500 mg /po /od 

5. Tab DOLO 650mg /po/sos 

6. NEBULISATION WITH DUOLIN /tid.                   BUDECORT /bd 

7. SYP LACTULISE 10ml /po/ HIS

 

Foley's removed and planned for ICD removal

Day 9

SOAP NOTES 

 A 65 yr old man with AKI SECONDARY TO UTI 

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

Subjective : 

 Pt complaints of burning micturition

Objective :

 Temp:98

 PR:94 

 RR: 22

 BP: 120/70mmhg 

 Grbs :100 

Assessment-

RENAL AKI SECONDARY TO UTI (ECOLI sps) 

WITH IATROGENIC HEMOTHORAX (SECONDARY TO CENTRAL LINE INSERTION) 

WITH ANEMIA SECONDARY TO BLOOD LOSS 

Plan of treatment - 

1.ORAL FEEDS

2. Inj PAN 40mg /iv / od 

3. TAB LASIX 40mg /po/ od 

4. Tab NODOSIS 500 mg /po /od 

5. Tab DOLO 650mg /po/sos 

6. NEBULISATION WITH DUOLIN /tid. BUDECORT /bd 

7. SYP LACTULISE 10ml /po/ HIS

Day 10

SOAP NOTES 

 A 65 yr old man with  AKI SECONDARY TO UTI 

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

Subjective : 

 Pt complaints of burning micturition

Objective :

 Temp:98

 PR:94 

 RR: 22

 BP: 120/70mmhg 

 Grbs :100 

Assessment-

RENAL AKI SECONDARY TO UTI (ECOLI sps) 

WITH IATROGENIC HEMOTHORAX (SECONDARY TO CENTRAL LINE INSERTION) 

WITH ANEMIA SECONDARY TO BLOOD LOSS 

Plan of treatment - 

1.ORAL FEEDS

2. Inj PAN 40mg /iv / od 

3. TAB LASIX 40mg /po/ od 

4. Tab NODOSIS 500 mg /po /od 

5. Tab DOLO 650mg /po/sos 

6. NEBULISATION WITH DUOLIN /tid.                   BUDECORT /bd 

7. SYP LACTULISE 10ml /po/ HIS

Day 11

SOAP NOTES 

 A 65 yr old man with  AKI SECONDARY TO UTI 

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

Subjective : 

 Pt complaints of burning micturition

Objective :

 Temp:98

 PR:94 

 RR: 22

 BP: 120/70mmhg 

 Grbs :100 

Assessment-

RENAL AKI SECONDARY TO UTI (ECOLI sps) 

WITH IATROGENIC HEMOTHORAX (SECONDARY TO CENTRAL LINE INSERTION) 

WITH ANEMIA SECONDARY TO BLOOD LOSS 

Plan of treatment - 

1.ORAL FEEDS

2. Inj PAN 40mg /iv / od 

3. TAB LASIX 40mg /po/ od 

4. Tab NODOSIS 500 mg /po /od 

5. Tab DOLO 650mg /po/sos 

6. NEBULISATION WITH DUOLIN /tid.                   BUDECORT /bd 

7. SYP LACTULISE 10ml /po/ HIS

Day 12

SOAP NOTES 

 A 65 yr old man with  AKI SECONDARY TO UTI 

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

Subjective : 

 Pt complaints of burning micturition

Objective :

 Temp:98

 PR:94 

 RR: 22

 BP: 120/70mmhg 

 Grbs :100 

Assessment-

RENAL AKI SECONDARY TO UTI (ECOLI sps) 

WITH IATROGENIC HEMOTHORAX (SECONDARY TO CENTRAL LINE INSERTION) 

WITH ANEMIA SECONDARY TO BLOOD LOSS 

Plan of treatment - 

1.ORAL FEEDS

2. Inj PAN 40mg /iv / od 

3. TAB LASIX 40mg /po/ od 

4. Tab NODOSIS 500 mg /po /od 

5. Tab DOLO 650mg /po/sos 

6. NEBULISATION WITH DUOLIN /tid.                   BUDECORT /bd 

7. SYP LACTULISE 10ml /po/ HIS