60 years old female with AKI on CKD

11/05/2021

Intern: Hema Pushpika

PG- I: Sai Charan

PG-II: A.Vaishnavi

Faculty on call : Dr. Vijaya lakshmi

This is an online e log book to discuss our patient de-identified health data 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 evidence based input

This E blog also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome

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.

A 60 year old female came with c/o pain abdomen in left loin region since 10 days

Decreased urine output since 10 days

Burning micturition since 10 days

h/o one episode fever 10 days back which is low grade and 2 episodes of vomiting for 2 days

Patient was apparently normal 20 years back , then she developed pain abdomen , decreased urine output then she was told that her right kidney was failed and she need to undergo nephrectomy if not her left kidney will be effected . Because of which she underwent nephrectomy 20 years back.

later she had suprapubic pain with burning sensation 7 years back and was told that she had a wonderful on cervix for which she underwent hysterectomy.

6 years back she had similar complaints for which conservative management was done

K/c/o Hypertension since 5 years and on medication 

Not a k/c/o DM/TB/BA

H/o decreased appetite since 10 days

On Examination:

Patient was conscious, coherent and cooperative

No signs of cyanosis, clubbing, lymphadenopathy

Fixed flexion deformity of knee:

Flat nails:

Temperature: afebrile

Pulse rate : 86 bpm

Respiratory: 16 cpm

BP : 150/90 mm Hg

Spo2: 96% at room air

GRBS: 160 mg/dl

Systemic examination:

CVS: S1,S2 HEARD

RS: BAE present

CNS: NFND

P/A:

INSPECTION:

Shape - obese

umbilicus- shape inverted , no herniations, no discharges

Movements on respiration - normal

Skin over abdomen is smooth and no pigmentation

no engorged veins, no visible pulsations

PALPATION:

Inspectory findings are conformed on palpation

Abdomen is soft 

Non tender

No organomegaly

No palpable masses

Auscultation : bowel sounds are heard

                                                                   Tunnel obesity:

INVESTIGATIONS:

TREATMENT:

 IVF 1 unit of  NS @ UO + 30 ML/HR

 INJ. LASIX 40 mg iv/bd IF SBP > 110 mmHg

 vitals monitoring

 strict i/o charting

 temperature monitoring