80 y/O male pt with AKI on CKD

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 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 a  diagnosis and treatment plan.

Imama muhmeen 

Roll no 163

Case of a 80y/o male with AKI ON CKD

My case is of a 80y/o male, resident of kurumarthy, nalgonda who used to be a farmer by occupation. 

Patient was brought to casuality for dialysis. 

(K/c/o CKD on MHD.

TIMELINE OF EVENTS 

10years back, developed giddiness with pedal edema 

(on & off)  then 

on routine check up diagnosed as hypertension. 

▪︎On regular medications.

(Chief complaints)

20 days back Patient developed fever associated with chills ,

        associated with burning micturition. 

Since 10 days Patient had altered behavior 

( uremic enceph, d dementia) 

Associated with decreased urine output.

History of Presenting Illness 

Patient went to a private hospital where they were told to have kidney problem and should undergo dialysis in view of raised Sr.creatinine (5.6)

10/1/22

 He was brought to mins casuality. His vitals showed

         B.P:  140/90 mmHg

         P.R: 99bpm

         SpO2: 78%(RA) 

                     96%(14L,O2)

          GRBS: 124mg/dl

Sob & pedal edema since 10 days

History of past illness 

  

    • H/o Bowel & Bladder Incontinence  (since past 2yrs)

    •  H/o HTN  ( past 10yrs)

    • NO DM / 

    • NO CAD

Personal History 

     Patient takes a mixed diet. Appetite is reduced (past 2 yrs)

     Bowel and bladder movement: irregular (Incontinence)

     No known allergies. 

     Habits : occasionally drinks alcohol (/toddy)

                    Occasionally smokes tobacco 

    

Family History 

No relevant family history

PHYSICAL EXAMINATION 

• GENERAL EXAMINATION 

      Pallor present, clubbing present 

      No cyanosis & Icterus , lymphadenopathy 

      Oedema of feet (mild)

       Malnourished, dehydrated (mild)

Temp ; afebrile

PulseRate ; 94/min

RR; 30/min

BP; 140/90

11/1/22

S: fever spikes

     Sob +

O: 

Bp : 110/70mmhg

PR:96bpm

Spo2:95% 10L OF O2

RR:28

Grbs:92mg/dl

Input /output :1000/500ml

(Cps ifany)

     •supra clavicular & infra clavicular.......... seen 

     •Scaphoid abdomen 

     •

X-ray: lung collapse?

SYSTEMIC EXAMINATION 

Cvs : S1, S2 + , No murmurs

RS : BAE + , dyspnea - yes!!

         B/L IAA crepts positive

          Wheeze: no

         Breath sounds: vehicular

P/A : soft, NT

         Liver and spleen : not palpable

          Bruritis: no

          Palpable mass: no

CNS : DROWSY, DLURRED SPEECH

           NO signs of meningeal infections 

       CN: not examined

       MS: ne

       SS: decreased sensation 

Gait: not done

Provisional Diagnosis : 

AKI on CKD 

With Aspiration pneumonia.

Associated with Hypertension. 

Investigations : 

 Hemogram, LFT, RFT, CXR, ECG,2DECHO,

USG-ABDOMEN - KIDNEY SIZE (-DECREASED)

                               RAPID CHANGES.

Fever chart?!

TREATMENT: 

 10/1/22

P:

TREATMENT GIVEN 

INJ.PAN 40 MG /IV/OD 

INJ.ZOFER 4 MG /IV/SOS 

IVF - NS @ UO+50 ML/HR 

INJ .LASIX 20 MG /IV/BD 

TAB PCM 650 MG /RT/SOS 

INJ PIPTAZ 2.25 G /IV/TID 

BP/PR/TEMP MONITORING 4TH HOURLY 

GRBS CHARTING 12 TH HOURLY 

2nd hourly oral suctioning

11/1/22

Plan of care : conservative

Prognosis: guarded