A Case of Acute Kidney Injury

August 06, 2021

Welcome to my blog! I am Varshitha Kalidindi, a 2nd year medical student. This is an e-log to discuss our patient's health data after taking consent of the patient. It also reflects patient centered care and online learning portfolio.

I will be looking forward to some feedback and valuable inputs through the comments box provided below.

This is an ongoing case which will still be regularly edited and updated.

CASE:-

An 80 year old female came to the hospital with complaints of shortness of breath, decreased appetite, decreased urinary output, abdominal distension, bilateral swelling of lower limbs since 1 week.

CHIEF COMPLAINTS:-

Shortness of breath, decreased appetite, decreased urinary output, abdominal distension, bilateral swelling of lower limbs since 1 week.

HISTORY OF PRESENT ILLNESS:-

The patient was apparently asymptomatic 20 days ago.

She then had complaints of generalized weakness of body, decreased appetite, difficulty in passing stools (once in 3 days). Later, the patient had complaints of bilateral swelling of lower limbs, pitting type, up to the knee. She also had decreased urinary output, abdominal distension.

She went to a local hospital and her symptoms didn't subside. She later went to another hospital. Since the past 3 days, the patient had complaints of cough with sputum, white in colour, mucoid.

The patient is a known case of post pulmonary tuberculosis 15 yrs back and she used prescribed medication.

The patient is a chronic alcoholic, daily 90ml/day. She is also a chronic smoker.

TREATMENT HISTORY:-

No history of diabetes, hypertension, CAD, asthma, surgeries, blood transfusions, chemo/radiation, hormones.

She is a known case of tuberculosis 30 years ago and used antituberculous drugs for 4-6 months.

PERSONAL HISTORY:-

Appetite: decreased

Diet: vegetarian

Bowels: constipation (passes stools once in 3-4 days)

Micturition: decreased urine output

Addictions: She occasionally drinks 90-180ml of whiskey. Her last smoking binge was 3-4 cigarettes in 10 days.

FAMILY HISTORY:-

No family history of diabetes, hypertension, heart disease, stroke, cancers, tuberculosis, asthma.

GENERAL EXAMINATION:-

No cyanosis, lymphadenopathy, icterus, clubbing of fingers/toes.

Pallor and oedema of feet were observed.

VITALS:-

Upon arrival at the hospital, the following were recorded:

Pulse rate: 110bpm

BP: 80/40mmHg

SPO2: 70

These values have been changing as logged below:-

SYSTEMIC EXAMINATION:-

CVS: S1, S2 sounds heard

Respiratory system: dyspnoea and wheeze present, position of trachea - central, breath sounds-vesicular. Decreased air entry in right IAA, IMA, ISA. Inspiratory creps in left IAA, IMA, ISA.

Abdomen: Shape of abdomen is scaphoid. Bowel sounds heard.

CNS: The patient is alert.

INVESTIGATIONS:-

Bacterial culture and sensitivity report - blood:-

Bacterial culture and sensitivity report - urine:-

Hemogram on 2/8/2021:-

Blood grouping and RH type:-

Complete Urine Examination (CUE):-

HIV 1/2 Rapid Test:-

HBsAg - RAPID:-

Anti HCV Antibodies - RAPID:-

SARS - COV - 2 Qualitative PCR:-

Dengue NS1 Antigen, IgG and IgM (RAPID TEST):-

Prothrombin time/PT on 4/8/2021:-

Hemogram on 4/8/2021:-

APTT on 4/8/2021:-

ABG on 3/8/2021:-

Blood Urea:-

Serum Creatinine:-

Serum Uric Acid:-

Serum Electrolytes (Na, K, Cl):-

Liver Function Test (LFT):-

RFT:-

Prothrombin Time (PT) on 3/8/2021:-

APTT on 3/8/2021:-

Erythrocyte sedimentation rate (ESR):-

D-Dimer:-

Hemogram on 3/8/2021:-

Blood sugar - Random:-

Urinary Electrolytes Na, K:-

Urinary Protein/Creatinine Ratio:-

T3, T4, TSH:-

ABG on 3/8/2021 (1):-

ABG on 3/8/2021 (2):-

PROVISIONAL DIAGNOSIS:-

Acute Kidney Injury (sepsis induced) with right heart failure, with congestive hepatopathy, with post TB sequale (chronic fibrosis and collapse), with mixed respiratory failure.

CROSS CONSULTATION NOTES:-