Acute kidney injury




E-LOGS GENERAL MEDICINE



 
Roll no 36
Hi, i am tejaswi5th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent. This also reflects patients centered care and online learning portfolio. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. Hope this will be informative!

* This is an ongoing case. I am in the process of updating and editing this ELOG as and when required.

A 53 yr old female patient came with cheif complaints of bilateral loin pain since 10 days , decreased urinary output since 5 days . She also complained of shortness of breath since anuria and constipation . 

History of present illness 


Paitent was apparently asymptomatic 20 yrs back and than developed generalised weakness for which she went to the hospital where she was diagnosed with diabetes for which she was given medicines . She continued the medication for abt 10 yrs later she was given insulin injections on inj mixtard 10 units morning and night. She also developed hypertension 10 yrs back for which she was given telma 40 mg but she soon discontinued her bp medication but continued the insulin . 
3 months back once she faced similar pain for which she went to hospital and it was treated and it subsided . 
Recently about 10 days back she developed bilateral loin pain for which she went to hospital in miryalguda where they told her she had urinay tract infection .she than resumed her bp mediacation . After that she came to our hospital 6 days back complaining of bilateral loin pain since 10 days ,decreased urinary output since 5 days , shortness of breath since 3 days , anuria and constiaption from 1 day 
She complained of vomitings immediately after intake of food and has reduced appetite . 
She also has pedal oedma pitting type .

Past history 

K/c/o diabetes since 20 yrs  10 yrs tablets later insulin subcutaneous 
K/c/o hypertension since  10 yrs 
No history of tb , seizures 

Treatment history 
 MIXTARD 10 units morning and night
Hypertension telma 40 mg od 

Personal history 
Married occupation housewife 
Appetite decread 
Non veg 
Bowel and bladder reduced 
Ni known allergies 
No addictions 


Family  history 
Not significant 

Menstrual historyy 
 Hysterectomy done 10 yrs back 

Allergic history 
No known allergies 

GENERAL EXAMINATION 

Pallor - Present 
Icterus - present 
Cyanosis- absent 
Clubbing- absent 
Lymphadenopathy- absent  
Edema - present bilateral pedal 

VITALS : 

Temperature – 98°F 
Pulse rate –90 per min 
BP –130/80
Respiration rate –14
GRBS –  112
SPO - 96 percent


SYSTEMIC EXAMINATION 
    CVS 
No Thrills 
Cardiac sounds S1,S2
No murmurs 

RESPIRATORY SYSTEM 

Dyspnoea - present 
Wheeze - absent 
Position of trachea - central 
Breath sounds are vesicular

ABDOMINAL EXAMINATION 

Abdomen  
No Tenderness 
No palpable mass 
Hernial orifices normal 
free fluid absent 
No bruits 
Liver is not palpable 
Spleen is not palpable 
Bowel sounds heard 

CNS 
 Conscious
Speech is normal 
Signs of meningeal irritation- no neck stiffness
                                                 



Investigations ordered 


              












Provisional diagnosis 

Acute kidney injury on ckd
2* to diabetes 
2* HTN 

Treatment 

1) fluid restriction less than 2l per day 
2) salt restriction less than 2 g per day 
3) INJ PIPTAZ 2.25 gm/ iv/TID
4)INJ CIPROFLAXICIN 250mg /iv/BD
5)INJ HAC
6) INJ ZOFER 4mg / iv 
7) T. OROFER 
8)T. SHELCAL


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