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Nephrostomy


GENERAL MEDICINE
    
Hello all. This is Tejaswi, a third-semester medical student. This e log depicts the patient-centered approach to learning. 

This is an online E Logbook recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

Note: This is an ongoing case and will be updated as and when we find new information.

55 YR OLD MALE PT WITH B/L HYDRONEPHROSIS 


CASE SHEET 

Date of admission:13/1/22



A 55 year old male patient, agricultural labourer by occupation,married, living with his wife , had one daughter (married, lives in Nalgonda)



 he is a resident of mutthayigudem came to 

KIMS , Narketpally on 13/01/22 with



CHIEF COMPLAINT :

o pain abdomen, decreased urine output, fever, nausea and vomiting since 20 days.


The patient was asymptomatic 4 months , when he developed b/l pedal edema ( upto ankle), decreased urine output, burning micturition, flank pain. 


HISTORY OF PAST ILLNESS:


3 months ago went to a hospital in Nalgonda with where he was diagnosed with b/l renal calculi



On 02/01/22 he went to a hospital in Nalgonda with chief C/O fever with chills and Rigors and generalised body pains for 3 days

USG report showed 

  1. Right gross pyonephrosis 
  2. Left gross hydronephrosis 

For which he was given medication and referred to urologist.


On 08/01/22 one of his relatives took him to a hospital in kammam 

where  USG showed

  1. Grossly hydronephrotic Rt kidney with almost no cortex, enlarged renal pelvis, due to proximal ureteric calculus of 2.1 cm 
  2. Severe hydronephrosis of Lt kidney seen with thinking of cortex, dilation of ureter due to ureteric calculus of 2.6 cm


Prostate enlarged 



Later on 13/1/22 he came to our hospital 


On CT abd:

  1. Gross HDN of Rt kidney with proximal ureteric calculus of 2 cm.
  2. Lt severe HDN with 2.6 cm mid ureteric calculus.


Pt underwent one session of dialysis on 15/01/22


Past  ILLNESS:


Pt is not a k/c/o HTN, DM, TB, Asthma, epilepsy.


PERSONAL HISTORY 




TREATMENT HISTORY


Took medication to relieve fever and pain 


PHYSICAL EXAMINATION:

GENERAL 

  •  Pallor - present 
  •  icterus - absent
  •  cyanosis - absent
  •  clubbing of fingers/toes - present
  •  dehydration - mild
  •  lymphadenopathy
  • Oedema - mild


VITALS : 

  •  temperature - febrile  - 99.7 
  •  pulse rate - 100bpm
  •  Bp- 140/80mm Hg
  • RR - 22cpm
  •  SPO2 - 99%
  • GRBS- 116mg%


SYSTEMIC EXAMINATION :


CENTRAL NERVOUS SYSTEM:
Pt, conscious, coherent, and cooperative
• Speech is normal
• no signs of meningeal irritation


CARDIOVASCULAR SYSTEM:

• S1, S2 +

RESPIRATORY SYSTEM:

BAE + NVBS

 ABDOMINAL EXAMINATION:

Pain in the right and left flanks 


INVESTIGATIONS 

RFT:

Urea- 278

Creat- 16

Na-134

K-6.1

Cl-104


Hemogram:

Hb-7.9

TC- 6,400

PLC- 2,40,000


CUE 

Alb- 1+

PC- 3-4


LFT:

TB- 0.99

DB- 0.28

AST-12

ALT-12

ALP- 174

TP-6.4

Alb-5.5


ABG:

PH- 7.21

Po2- 131

Pco2-14.5

Spo2-96

HCo3-5.7


ECG ON 13/01/22

On 19/01/22

Day 6




S:

C/o fever with chills 

1 g neomol given 




Last session of haemodialysis on 15/01/22


O:

Temp-101.6F

BP- 110/90 mmhg

PR- 96 bpm

RR- 19 cpm



Sr. Creat-10.6

Urea-217

Na-135

K-5.1

Cl-94


A:

Post renal AKI secondary to b/l hydronephrosis with refractory hyperkalemia ( secondary to renal calculus ) with  metabolic acidosis 


P:

IV fluids

Inj lasix 20 mg IV/BD

Inj Pan 40 mg IV/OD

Inj Zofer 4 mg IV/TID

Inj Thiamine 1 amp in 150 ml NS IV/OD 

Tab PCM 650 mg PO/SOS

Tab. Nodosis 500 mg PO/BD

Tab Orofer XT PO/OD

Salt restriction < 2.4 g/ day


LEFT PERCUTANEOUS NEPHROSTOMY UNDER LOCAL ANAESTHESIA DONE ON 19/01/22


USG ABDOMEN 




Findings:


1. Grade II RPD changes in Lt kidney

2. Grossly dilated PCS of Rt kidney compressing the renal parenchyma.




 

20/1/21

Day 7 


S : SOB reduced 

Fever spikes present 104 F

Cough reduced


One session of haemodialysis done on 19/1/22



O/E pt c/c/c

Febrile 102.6 F

BP - 100/70

PR - 88bpm

CVS - S1S2+

RS - BAE+

P/A - soft, non tender

One session dailysis done on 14/01/22

Creatinine : 16.3 --> 9.5

Urea : 278 --> 162 --> 217


A: 

Post renal AKI secondary to b/l hydronephrosis with refractory hyperkalemia ( secondary to renal calculus ) 


P : To watch for reduction of urea and creatinine.



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