A 70 year old female patient with Acute kidney injury secondary to urosepsis on chronic kidney disease secondary to hypertension nephropathy

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CHIEF COMPLAINT:

A 70 years old female, who is a housewife came to OPD with chief complaints of lower backache with generalised waekness(unable to sit) since 1 week and decreased urine output  since 3 days, bilateral pedal edema since 3 days.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic one week back then she developed  Bilateral loin pain radiating upto inner thigh since 2-3 years, which is increased from last one week associated with decreased urine output and bilateral pedal edema upto ankle.

She is evaluated as hyponatremic (dyselectrolytemia)

Na+ = 117 mEql/L

K+ = 2.8 mEql/L

PAST HISTORY:

She is a known case of CKD since 2016 and hypertension since 5 years

Not a known case of diabetes, asthma, epilepsy, tuberculosis 

She underwent HD (HEMODIALYSIS) in 2019.

TREATMENT HISTORY:

she is on conservative management along withHypertension on regular medication 

She underwent HD (HEMODIALYSIS) in 2019.

PERSONAL HISTORY:

Appetite-  loss of appetite 

Diet- mixed

Bowel habits- regular 

Bladder habits-  decreased urine output from 3 days

Sleep- adequate 

Addictions- no addictions

Allergies- no allergies

FAMILY HISTORY:

Insignificant 

GENERAL EXAMINATION:

Conscious, coherent and cooperative 

Well oriented to time, place and person 

Moderately built and moderately nourished 

Pallor- PALLOR PRESENT (severe)

Icterus- No icterus

Cyanosis- No Cyanosis 

Clubbing- No clubbing 

Generalised lymphadenopathy- No generalised lymphadenopathy 

Pedal edema- BILATERAL PEDAL EDEMA UPTO ANKLE

Malnutrition- No

Dehydration-  Mild

Vitals:

Day-1:

Temperature - afebrile 

Pulse rate- 93 bpm

Respiratory Rate- 14 cycles per minute

Blood Pressure- 160/80 mm of Hg

GRBS- 152 mg/dl

Day-2:

Temperature - afebrile 

Pulse rate- 96 bpm

Respiratory Rate- 14 cycles per minute

Blood Pressure- 150/60 mm of Hg

GRBS- 152 mg/dl

Day-3:

Temperature - afebrile 

Pulse rate- 84 bpm

Respiratory Rate- 14 cycles per minute

Blood Pressure- 170/90 mm of Hg

SpO2- 100% at room air

GRBS- 176 mg/dl

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM- S1 and S2 heart sounds heard, no murmers and thrills

RESPIRATORY SYSTEM- Bilateral air entry present with vesicular breath sounds and no added sounds. No dyspnoea, wheeze

CENTRAL NERVOUS SYSTEM- intact

Consciousness  - Conscious

Speech - normal

Signs of meningeal irritation :

 Neck stiffness - no

kerning's sign - no

Cranial nerves- normal 

Motor system - normal

Sensory system - normal 

Glassgow scale - normal

PER ABDOMEN- no organomegaly 

Shape - scaphoid

Tenderness - non tender

Palpable mass - no

Hernial orifices- normal

Liver - not palpable 

Spleen - not palpable

Bowel sounds - heard and normal

Genitals - normal

INVESTIGATIONS:

RAPID ANTIGEN TEST: NEGATIVE 

ABG:

Day -1;

pH - 7.26 

pCO2- 20 mm Hg

SpO2- 95.9%

Serum HCO3 = 11.5 mmol/L

HCO3(a) = 8.7 - 8.0

Day-2;

Serum electrolytes:

Day-1;

Day-2;

Serum creatinine:

Day-1;  6mg/dl

Day-2;  5.7mg/dl

Hemogram:

Blood urea:

Day-1;  91mg/dl

Day-2;  132 mg/dl

DIAGNOSIS:ACUTE KIDNEY INJURY(AKI) SECONDARY TO UROSEPSIS ON CHRONIC KIDNEY DISEASE(CKD) SECONDARY TO HYPERTENSION NEPHROPATHY.

TREATMENT:

Day-1;

IVF NS or RL 10.9% at 100ml/hour

INJ. PIPTAZ 2.25gm/IV/BD

INJ. PANTOP 40mg/IV/OD

TAB. NICARDIA 20mg/PO/BD

TAB. NODOSIS 550mg/PO/TID

TAB. OROFER-XT/PO/BD

TAB.SHELCAL /PO/OD

INJ. ERYTHROPOIETIN 4000IU/SC WEEKLY ONCE

INJ. NaHCO3 100mEql/slow IV/stat/

INJ, TRAMADOL 1 amp in 100NS/IV/BDAFTER INJ. ZOFER 4CC/BD

SYRUP. POTCHLOR 16ml/PO/TID

INJ. LASIX 40mg/IV/BD

Advice:

ORTHOPAEDIC opinion for bilateral hip pain

ORTHOPAEDIC ADVICED TREATMENT:

TAB. DOLO 650mg BD FOR 1 WEEK

TAB. SHELCAL OD FOR 3 WEEKS

TAB. LIMCEE TID FOR 10 DAYS

Day-2;

IVF.NS(0.9%) AT 75ml/hour if altered sensorium persists,

 3%NaCl at 10ml/hour

INJ. PIPTAZ 4.5gm/IV/stat after sending urine sample

 INJ. PIPTAZ 2.25gm/IV/BD

INJ. PANTOP 40mg/IV/OD

TAB. NICARDIA 20mg/PO/BDBP/PR/TEMPERATURE/ SpO2 HOURLY STRICT I/O CHARTINGTAB. 

NODOSIS 550mg/PO/BD

TAB. OROFER- XT /PO/BD

INJ. ERYTHROPOIETIN 4000IU/SC/ONCE WEEKLY