A 65 year old female presented to Opd with chief complaints of
-Abdominal distension since 4 days
-Diffuse abdominal pain since 4 days
-decreased urinary output since 4 days
-Burning micturition since 4 days
-Constipation since 2 days
HOPI
Patient was apparently asymptomatic 4 days back then she developed burning micturition not associated with suprapubic tenderness, loin pain, fever and chills.
It is associated with decreased urinary output since 4 days.
Diffuse abdominal pain present since 4 days which was spasmodic type non radiating. No aggravating and relieved on medication.
There is history of fluid loss 4 days back ( vomitings 2 episodes )
Past History
She is a k/c/o DM type 2 since 6 months and is using medication for it (Metformin 500 mg OD)
She is a k/c/o HTN since 3 years and is on medication for it (T.atenolol 50mg and T.amlodipin 5mg)
Patient is not a k/c/o TB, Asthma, Epilepsy, CAD and CKD
Drug History
Not allergic to any known drugs.
Personal History
Diet : mixed
Appetite : normal
Sleep : adequate
Bladder : decreased urine output since 4 days
Bowel : constipation since 4 days
Family History
Not significant
General Examination
Patient is conscious,coherent and cooperative. Moderately nourished and well built.
Temperature : Afebrile
Pulse rate : 84bpm
BP : 110/70 mm hg
RR : 16 cycles per min
SPO2 : 96%
GRBS : 125mg%
No signs of pallor, icterus, cyanosis, clubbing, kilonychia, generalised lymphadenopathy.
h/o bilateral pedal edema progressing upto knee.
Respiratory system
Normal vesicular breath sounds heard
Bilateral air entry present
Dyspnoea- present (grade 2)
Wheeze- no
Position of trachea- central
Breath sounds- vesicular
Adventitious sounds- B/L coarse crepts
CVS
Cardiac sounds : S1 S2 heard
No murmurs heard
Per Abdomen
Shape : scaphoid, soft
no tenderness and local rise of temperature.
no palpable mass
hernial orifice : free
no free fluid , no bruits heard
liver and spleen - not palpable
bowel sounds- sluggish
CNS
Patient is conscious, coherent, cooperative well oriented to time place and person.
Higher mental functions- normal
cranial nerves- intact
motor system- normal
sensory system - normal
Based on the above findings, following investigations were sent
1. ABG
2. PT , APTT
3. BT, CT
4. RFT
5. LFT
6. CUE
7. Bacterial culture and sensitivity
8. USG
9. FBS
10. Chest x ray
Diagnosis :
Pre renal AKI with Urosepsis with hypoalbuminemia and k/c/o DM type 2 , HTN with Grade 2 fatty liver.
Treatment:
1) Inj pantop 40mg/iv/stat
2) Inj piptaz 4.5gm/iv/stat
3) Inj piptaz 2.25iv/qid
4) IVF U.O + 30ml/hr NS
5) GRBS 6th hourly Inj HAI sc
6) Inj lasix 20mg/IV/stat
7) Inj lasix 20mg/IV/bd if SBP > 110 mm hg
8) syp lactulose 30 ml bd if stools are not passed
9) maintain MAP > or = 65-70 mm hg
10) protein X powder 2 tbsp in one glass milk BD
11) 2 egg whites per day
12) BP, Temp, PR charting hourly
13) I/O charting strictly
Patient was sent to dialysis on 27/12/20 indication being anuria.
Follow up:
Following investigations were repeated :
1. ABG
2. Hemogram
3. CBP
4. Blood urea
5. Serum creatinine
6. RFT
Patient was sent to dialysis on 21/12/20 due to increased blood urea levels. Patient potassium levels were decreased and she was given syp potchlor.
Patient was sent to dialysis 27/12/20 due to increased blood urea and serum creatinine.
Advice at discharge :
- Salt(<2g/day) and fluid (<1.5lit/day) restriction
-Tab nodosis 500mg bd
-Tab aldactone 50mg od
-Tab amlong 5mg od
-Tab shelcal 500mg od
-Syp potchlor 10ml in one glass of water tid for
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