AKI on CKD 2°to post renal, bilateral gross hydrourethronephrosis,right mid ureteric calculians s/p 3 sessions of hemodialysis 1 yr back

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A 45 year old female patient came to opd with chief complaints of reduced urine output since 1 week, easy fatigability since 1 week, shortness of breath since 3 days.

H/o presenting illness:-

Patient was apparently asymptomatic 1 week back later she developed reduced urine output and easy fatigability.SOB since 3 days , progressed to grade 3 to 4 (NYHA).

H/o hemodialysis of 3 sessions 1 year back.

Dialysis was initiated due to deranged RFT, metabolic acidosis to remove toxic metabolites. 

Patient had no response to speech from evening after hemodialysis. 

Today (18/2/22)- there was response and was orientated to time, place and person.

Past h/o:

Not a known case of Hypertension,Diabetes mellitus, Hypertension, Coronary Artery Disease, Chronic Kidney Disease, Asthma.

 

Vitals on admission:

Temperature: afebrile 

PR: 98 bpm

RR: 22cpm

BP: 160/80 mm Hg 

SpO2: 98%

GRBS: 106 mg/dal

CVS: S1 S2 present 

RS: BAE +

Treatment-

Inj lasix 50 mg iv /bd

Inj pan 40 mg iv /od

Inj.zofer 4 mg iv/od

Inj erythropoietin 4000iu s/c once weekly

Tab. Nodosis 500 mg po/bd

Tab.orofer ct po/od

Tab .shelcal po/od

Monitor vitals hourly.

INVESTIGATION ON 15/2/22

serology -negative

RBS-75

S.iron -62

BGT- B POSITIVE

ECG on 15/2/22

Usg on 15/2/22  - b/l hydrourethronephrosis

urology opinion ivo b/l hydrourethronephrosis

 

2D echo on 16/2/22

ECG ON 17/2/22

On 17/2/22 I/v/o hemodialysis- central line was placed.

Soap notes on 18/2/22

ICU BED 4

45Y/F

S:2 episodes of vomitings

O:

BP:120/80 MMHG

PR:112BPM

RR:22CPM

CVS:S1S2+

RS:BAE+

P/A: Soft, nontender

A: AKI on CKD 2° to post renal, bilateral gross hydrourethronephrosis,right mid ureteric calculians s/p 3 sessions of hemodialysis 1 yr back

P:inj.piptaz 2.25 gm iv /tid

Inj metrogyl 500mg 100ml iv /tid

Tab.nodosis 500 mg po/bd

Tab.shelcal ct po/od

Tab.orofer xt po/bd

Tab.zofer 4 mg iv/tid

RT foods- with 100 ml milk- 4 th hourly

100 ml water - 2 nd hourly

Underwent hemodialysis yesterday evening

HYPOTHYROIDISM DENOVO

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box

A 40 YR OLD FEMALE CAME TO OPD WITH C/O FACIAL PUFFINESS,PEDAL EDEMA,SOB SINCE 1 MONTH

PATIENT WAS APPARENTLY ASYMPTOMATIC 1 YR BACK, SHE HAD SIMILAR COMPLAINTS LIKE FACIAL PUFFINESS,PEDAL EDEMA WENT TO LOCAL HOSPITAL SAID TO HAVE LOW HB -6.5 GM/DL- PUT ON ORAL MEDICATION. PATIENT USED MEDICATION FOR 2 MONTHS , HB IMPROVED TO 10 GM /DL. 

SIMILAR COMPLAINTS SINCE 1 MONTH FACIAL PUFFINESS,PEDAL EDEMA,SOB- INSIDIOUS IN ONSET, NON PROGRESSIVE GRADE 2 ACC TO NYHA. NOT ASSOCIATED WITH ORTHOPNEA AND PND.

H/O WT. GAIN + ,DRY SKIN+ COLD INTOLERANCE+.

NO CONSTIPATION, FATIGUE, MENSTRUAL DISTURBANCES.

NO H/O DEC. URINE OUTPUT, FEVER ,COLD, COUGH,PAIN ABDOMEN.

No h/o DM,HTN,TB,BA , epilepsy

FAMILY H/O: 

Daughter k/c/o : hypothyroidism since 2015 and on medication THYRONORM 50 mg /od 

GE: Pt is c/c/c, afebrile

Bp- 100/60 mm Hg

PR-80 bpm

RR-20 cpm

Spo2-99%@ RA

Grbs-92 mg/dl

Clubbing+

No pallor, icterus, cyanosis lymphadenopathy

CVS: S1S2+ 

RS: BAE+

CNS: NAD

 

PROVISIONAL DIAGNOSIS

Denovo diagnosed ? Primary HYPOTHYROIDISM.

 Treatment:

Tab. THYRONORM 75 MG OD

Anemia and renal failure secondary to ? Multiple Myeloma, AKI secondary to left lower limb cellulitis / ? Multiple myeloma, Recurrent cellulitis secondary to ? cutaneous vasculitis/amyloidosis ,k/c/o htn and denovo DM 2

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box

A 67 YEAR old male came with c/o left lower limb swelling since 10 days , fever since 10 days ,SOB on exertion since 3 days 

HOPI:

Patient was apparently asymptomatic 5 yrs back,on routine investigation diagnosed as hypertensive (on medication tab. amlo 5mg ) and had b/l knee pains since 4 yrs back underwent knee replacement- 3 yrs back had developed Left limb swelling and serous discharge for which he underwent debridement and fasciotomy. Patient was taken to pulse hospital-stay for 1 month (creat : 5.8 to 3.8). Since 1 month c/o right ear pain .

On 27 th jan patient c/o lower limb swelling- sudden onset , gradually progressive to current state, aggrevated on walking ,relieved on rest and limb elevation , swelling associated with pain which is insidious in onset , non progressive, intermittent aching type ,aggrevated with movements, relieved. with medications.

Fever since 10 days intermittent,high grade associated with chills and rigor .

SOB - Insidious onset, gradually progressive from grade 1 to 2 since 3 days ,no orthopnea/pnd.

No h/o burning sensation of urine , decrease urine output.

Past h/o: 

Hypertension since 5 yrs not on regular medication (amlo- 5mg, aten-50 mg)

Diabetes- denovo 2 days ,not on any medication,

Surgery- B/Lknee replacement

No h/o BA,TB,CVA 

Addictions: smoking- 1 to 2 cigarettes/day since 20 years, stopped 1 month back

General examination:

pallor -++

oedema of feet + left lower limb

on local examination- oedema of left LL + involving foot ,ankle and leg 

Tiny ulcers + largest  1x1 cm over Posterior aspect of leg, multiple patches of skin loss +,mild local erythema+, tenderness+ , pitting edema + , peripheral pulses +

On 11/2/22

On 14/2/22

 on 15/2/22

No cyanosis, icterus, clubbing, lymphadenopathy.

Vitals: temp:afebrile, PR :106bpm,RR: 18 cpm, spo2 : 98@ ra , BP:120/80 MMHG, GRBS : 134 mg/dl

CVS: S1S2+ ,JVP raised

RS: BAE+

CNS: NAD

PROVISIONAL DIAGNOSIS: AKI 2° TO LEFT LOWER LIMB CELLULITIS ,CKD 2° TO ANALGESIC NEPHROPATHY

 H/O HTN WITH DENOVO - DM 

 ANAEMIA UNDER EVALUATION ? MULTIPLE MYELOMA

 RIGHT EAR PAIN UNDER EVALUATION  

On  27/12/21

Treatment: on day 1

1.IVF- NS,RL at uo+30 ml/hr

2. Inj . Clindamycin 600 mg iv BD 

3. Inj. Piptaz 2.25 gm iv/TID

4. Inj pantop 40 mg iv OD

5. Inj zofer 4 mg iv sos

Surgery refferal

AMC BED 8 SOAP NOTES ON 12/2/22

S: decreased SOB

O: BP:130/90 mmHg

PR:90 bpm

RR:23 cpm 

SPO2: 95% RA

RS:BAE+

CVS: S1S2 + ,JVP increased

P/A:Obese,bs+

CNS:NAD

I/O:3100/2250

Grbs: yesterday

@8am-119,@2 pm- 138,@ 8pm-117,  today @8am-151

A: AKI SECONDARY TO LEFT LOWER LIMB CELLULITIS ,CKD SECONDARY TO ? ANALGESIC NEPHROPATHY 

H/o HTN ( not on regular medication) ,denovo DM2

ANAEMIA UNDER EVALUATION ? MULTIPLE MYELOMA

P:Monitor vitals 4 hrly

1.IVF-NS,RL at uo+30 ml/hr

2. Inj . Clindamycin 600 mg iv BD 

3. Inj. Piptaz 2.25 gm iv/TID

4. Inj pantop 40 mg iv OD

5. Inj zofer 4 mg iv sos

Ortho and ENT referral

On 14/2/22 AMC BED 8 -67y/M

S: decreased SOB

O: BP:130/90 mmHg

PR:90 bpm

RR:23 cpm 

SPO2: 95% RA

RS:BAE+

CVS: S1S2 + ,JVP increased

P/A:Obese,bs+

CNS:NAD

I/O:2300/1900

Grbs: 200 mg/dl

A: 1) Anemia and renal failure secondary to ? Multiple Myeloma

2) AKI secondary to left lower limb cellulitis / ? Multiple myeloma

3) Recurrent cellulitis secondary to ? cutaneous vasculitis/amyloidosis 

4) k/c/o htn and denovo DM 2

P: Inj.PIPTAZ 2.25 gm iv TID

Inj.CLINDAMYCIN 600 mg iv BD

CIPLOX EAR DROPS 3/3/3- RE

Ivf ns , rl at uo +30 ml/hr

Inj.lasix 40mg iv /bd 

Monitor vitals 4 hrly

This patient has 1)anemia.

(Peripheral smear showing microcytosis ,spherocytes , Target cells , rouleax formation)

2) Renal failure

3) Hypercalcaemia (corrected calcium - 11.4 mg/dl)

4) Gamma gap - (TP-7.3;alb-2.54 ; globulin-5)

So Multiple myeloma can be a possibility . 

Pathology are willing to do bone marrow biopsy

His recurrent cellulitis can also be due to cutaneous myeloma/amyloidosis.

Serum electrophoresis was sent .

  soap notes on 16/2/22

AMC BED 8 -67y/M

S: decreased SOB,C/o pain in left lower limb

O: BP:110/90 mmHg

PR:90 bpm

RR:23 cpm 

SPO2: 97% RA

RS:BAE+

CVS: S1S2 + 

P/A:Obese,bs+

CNS:NAD

I/O:1900/1250

Grbs: yesterday @8am-108, @2pm- 102,@8pm-96

today@8am -98

A: 1) Anemia and renal failure secondary to ? Multiple Myeloma

2) AKI secondary to left lower limb cellulitis / ? Multiple myeloma

3) Recurrent cellulitis secondary to ? cutaneous vasculitis/amyloidosis 

4) k/c/o htn and denovo DM 2,b/l knee replacement done 4 yrs back

5)Mass in the right external ear 

6)left knee synovitis

P: inj. MEROPENEM 1 gm iv /bd( day 2)

TAB.ultracet po/qid

CIPLOX EAR DROPS 3/3/3- RE

Ivf ns0.45 with 1 amp optineuron,rl at uo +30 ml/hr

inj HAI S/c 2u---2u--2u

Inj.lasix 40mg iv /bd 

Monitor vitals 4 hrly

frequent change of posture,left  lower limb elevation

YESTERDAY BONE MARROW ASPIRATION WAS DONE, REPORT AWAITING.