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.

 

This is an online e log book to discuss our patient de-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 evident based input.

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

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.  

  

Acute Kidney Injury secondary to Urosepsis

June 19, 2021

A 60yr old female presented to the OPD with chief complaints of pedal edema since 10 days, decreased urine output since 10 days and fever since 10 days.

History of present illness:

The patient was apparently asymptomatic 10years back following which she was diagnosed with DM2 on checkup and on Teneligliptin 20 mg. In 2019 ( 2 years ago) she developed fever, shortness of breath and pedal edema and diagnosed with Acute kidney injury secondary to urosepsis and resolved conservatively after dialysis (4 sessions)

Now presented with history of fever, high grade since 10 days, not associated with vomiting and loose stools . Patient complaints pedal edema bilateral and pitting type, with decreased urine output and burning micturition.

History of past illness:

Outside reports suggest acute kidney injury. Known case of diabetes mellitus since 10 years and on tab Teneligliptin 20 mg and not known case of hypertension, bronchial asthma, tuberculosis.

Personal history:

• Married 
• Mixed diet
• Normal Apetite 
• Adequate sleep
• Bowel movement is regular
• Decreased urine output and burning micturition
• With no known allergies.
• Consumes alcohol occasionally.

Family history:

No significant family history

General examination:

• There is Pallor 
• There is no Icterus, cyanosis, clubbing
• Generalized Lymphadenopathy
• Edema is seen bilaterally witch is Pitting type pedal edema. 

Vitals:

• Temperature afebrile
• Pulse rate is 111 beats per minute
• Respiratory rate is 24 cycles per minute
• Blood pressure measured on the left hand is 170/110 mm of Hg
• Oxygen saturation at room air is 90 arm per mm Hg

Systemic examination:

Abdominal system:

• No scars, sinuses, or any engorged veins.
• Hernial orifices intact
• Tenderness or guarding absent
• No enlargement of liver, kidneys, or spleen
• No ascites
• Bowel sounds were normal.

Cardiovascular system:

• cardiac sounds S1 S2 heard.
• No cardiac murmurs
• Thrills absent

Respiratory system:

• No chest wall deformity 
• Trachea central
• Expansion is symmetrical
• Percussion note is resonant
• Breath sounds normal, no wheeze or crackles heard.
• Vocal resonance normal and symmetrical

Central nervous system:

• No focal abnormality detected
• Higher mental functions intact 
• Cranial nerves intact 
• reflxes normal
• Speech normal

Provisional diagnosis:

• Acute kidney injury secondary to urosepsis

Investigations ordered:

14/06/21

1. Complete urine examination: 

2. ECG:

15/06/21:

1. Serum creatinine:

2. Blood sugar Fasting:

3. Blood sugar Random:

4. Blood Urea:

5. Serum Electrolytes:

6. Serum Potassium:

7. Urinary Chloride:

8. Urinary Potassium:

9. Urinary Sodium:

16/06/21

1. Serum Electrolytes:

 

2. Serum Creatinine:

3. Haemogram:

4. Blood urea:

5. ABG:

18/6/21

1. Serum creatinine:

2. Serum Electrolytes:

3.Haemogram:

4.Blood urea:

21/6/21

1. Complete Blood Picture (CBP)

Blood urea:

15/6/21 - 65 mg/dl

16/6/21 - 62 mg/dl

18/6/21 - 76 mg/dl

21/6/21 - 81mg/dl

Serum creatinine:

15/6/21 - 3.4 mg/dl

16/6/21 - 3.4 mg/dl

18/6/21 - 3.2 mg/dl

21/6/21 - 3.1 mg/dl

Total leukocytes count:

16/6/21 - 24700

18/6/21 - 26500

21/6/21 - 31700

Serum Electrolytes:

15/6/21 - Na: 139 ; K: 5.2 ; Cl: 106

16/6/21 - Na: 138 ; K: 5.1 ; Cl: 105

18/6/21 - Na: 136 ; K: 4.9 ; Cl: 102

21/6/21 - Na: 134 ; K: 5.5 ; Cl: 98

Diagnosis:

Acute kidney injury secondary to urosepsis with hyperkalemia ( resolved)

With anenmia of chronic disease 

Treatment:

15/06/21:

Treatment:

• Inj LASIX 40mg (8am- 2pm -8pm)
• IVF - NS @ UO + 50 ml/hr

15/6/21, 5:30 p.m.

Treatment:

• Inj LASIX 40mg (8am -2pm -8pm)
• IVF - NS @ UO + 50 ml/hr

16/6/21

Treatment:

•  Inj LASIX 40 mg IV/TID          1 -1 - 1
•  IVF - NS @ UO + 50 ml/hr
•  Inj MAGNEXFORTE 1.5 gm/IV/BD
•  Tab NODOSIS - XT PO/OD
•  Inj HAI s/c
•  Neb plain Asthalin 4 respules              1 - 1 - 1 - 1

17/6/21

Treatment:

•  Inj LASIX 40 mg IV/TID    1 -1 - 1
•  IVF - NS @ UO + 50 ml/hr
•  Inj MAGNEXFORTE 1.5 gm/IV/BD
•  Tab NODOSIS - XT  PO/OD
•  Tab OROFEA - XT  PO/OD
•  Inj HAI s/c
•  Neb plain Asthalin 2 respules
•  Strict I/O charting

18/6/21

Treatment:

•  Inj LASIX 40 mg IV/TID   1 -1 - 1
•  IVF - NS @ UO + 50 ml/hr
•  Inj MAGNEXFORTE 1.5 gm/IV/BD
•  Tab NODOSIS - XT  PO/OD
•  Tab OROFEA - XT  PO/OD
•  Inj HAI s/c
•  Neb plain Asthalin 2 respules  QID
•  Strict I/O charting
• Tab ULTRACET 1/2 tab QID   1/2 - 1/2 - 1/2 - 1/2

19/6/21

Treatment:

•  Inj LASIX 40 mg IV/TID    1 -1 - 1
•  IVF - NS @ UO + 50 ml/hr
•  Inj MAGNEXFORTE 1.5 gm/IV/BD
•  Tab NODOSIS - 500 mg  PO/OD
•  Tab OROFEA - XT  PO/OD
•  Inj HAI s/c
•  Neb plain Asthalin 2 respules  QID
•  Strict I/O charting
•  Tab ULTRACET 1/2 tab QID           1/2 - 1/2 - 1/2 - 1/2

Expected discharge summary:-

A 60yr old female presented to the OPD with chief complaints of pedal edema since 10 days, decreased urine output since 10 days and fever since 10 days.

History of present illness:

The patient was apparently asymptomatic 10 years back following which she was diagnosed with DM2 on checkup and on Teneligliptin 20 mg. In 2019 ( 2 years ago) she developed fever, shortness of breath and pedal edema and diagnosed with Acute kidney injury secondary to urosepsis and resolved conservatively after dialysis (4 sessions)

Now presented with history of fever, high grade since 10 days, not associated with vomiting and loose stools . Patient complaints pedal edema bilateral and pitting type, with decreased urine output and burning micturition.

History of past illness:

Outside reports suggest acute kidney injury. Known case of diabetes mellitus since 10 years and on tab Teneligliptin 20 mg and not known case of hypertension, bronchial asthma, tuberculosis.

Personal history:

• Married 
• Mixed diet
• Noamal Appetite 
• Adequate sleep
• Bowel movement is regular
• Decreased urine output and burning micturition
• With no known allergies.
• Consumes alcohol occasionally.

Family history:

No significant family history

General examination:

• There is Pallor 
• There is no Icterus, cyanosis, clubbing
• Generalized Lymphadenopathy
• Edema is seen bilaterally witch is Pitting type pedal edema. 

Vitals:

• Temperature afebrile
• Pulse rate is 111 beats per minute
• Respiratory rate is 16 breaths per minute
• Blood pressure measured on the left hand is 170/110 mm of Hg
• Oxygen saturation at room air is 90 arm per mm Hg

Systemic examination:

Abdominal system:

• No scars, sinuses, or any engorged veins.
• Hernial orifices intact
• Tenderness or guarding absent
• No enlargement of liver, kidneys, or spleen
• No ascites
• Bowel sounds were normal.

Cardiovascular system:

• cardiac sounds s1 and s2 heard normally
• Apex beat located in 5th ICS, medial to the mid-clavicular line.
• No cardiac murmurs
• Thrills absent

Respiratory system:

• No chest wall deformity 
• Trachea central
• Expansion is symmetrical
• Percussion note is resonant
• Breath sounds normal, no wheeze or crackles heard.
• Vocal resonance normal and symmetrical

Central nervous system:

• No focal abnormality detected
• Higher mental functions intact 
• Cranial nerves intact 
• Speech normal

Provisional diagnosis:

• Acute kidney injury secondary to urosepsis

Course in the hospital:-

Day 1:-
Treatment:

• Inj LASIX 40mg (8am- 2pm -8pm)
• IVF - NS @ UO + 50 ml/hr

Day 2:-

•  Inj LASIX 40 mg IV/TID          1 -1 - 1
•  IVF - NS @ UO + 50 ml/hr
•  Inj MAGNEXFORTE 1.5 gm/IV/BD
•  Tab NODOSIS - XT PO/OD
•  Inj HAI s/c
•  Neb plain Asthalin 4 respules    [ 1 - 1 - 1 - 1 ]

Day 2:-
same treatment was continued

•  Tab OROFEA - XT  PO/OD
•  Strict I/O charting was advised

Day 3:-same treatment was continued

• Tab ULTRACET 1/2 tab  QID [ 1/2 - 1/2 - 1/2 - 1/2 ] was added.

Day 4 and day 5:-same treatment was continued

Day 6:-

Same treatment was continued

•  Tab Norflox 200 mg PO/OD was added

Day 7:-

Same treatment was continued

•  Tab SHELCAL-CT PO/OD was added

Day 8:-same treatment was continued