A69 YR OLD MALE WITH BILATERAL HYDROURETERO NEPHROSIS AND AKI ON CKD
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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT .
Name : Ankitha reddy
Roll no : 67
Serum creatinine :
CUE :
Hemogram :
Blood Urea :
CBP :
LFT :
CT-KUB :
USG :
CASE :
A 69 year old male who is farmer by occupation came to the opd with cheif complaints of :
B/L pedal edema present since 15 days
Burning micturation since 15days
Increased frequency of micturition (10-15times per day ) and urgency
Nocturia 5-6 times
Itching all over the body since 7 days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 15 days back and later he developed bilateral pedal which is pitting type of edema since 15 days and buring micturition .
There is increased frequency of urination i.e; 10 to 15times per day and nocturia with 5 to 6 times at night.
Past history:
Patient had chronic eczema over right lower limb with uremic pruritis and generalised xerosis for which he was using liquid parafin and diphenaramine hydrochloride tablets.
He was not a known case of DM,HTN,Asthma
Personal history:
Diet : Mixed diet
Sleep : disturbed because of nocturia with a frequency of 5 to 6 times
Bowel movements are regular
Bladder movements had increased frequency of micturition and urgency with 10 to 15times per day.
Addictions : occasional drinker
GENERAL EXAMINATION :
Patient was consious cooperative and well oriented to time place and person.
PALLOR : absent
Icterus : absent
Lymphadenopathy : Absent
Clubbing : Absent
Edema : Bilateral Pedal Edema present
VITALS :
Temp: 98F
Respiratory rate : 16 cpm
Pulse rate: 82bpm
Bp : 110 /80 mm of hg
Spo2 : 92 at room pressure.
Systemic examination:
CVS : no murmurs heard, s1 and s2 heard
Respiration :no dyspnea and vesicular breath sounds are heard.
Abdomen : Normal
But itching over the upper abdomen
CNS : normal reflxes and intact senses.
SKIN: chronic exzema with genralized xerosis on right lower limb
Renal function tests :
PROVISIONAL DIAGNOSIS:
a patient developed AKI on CKD with bilateral hydrouretero nephrosis.
TREATMENT :
Inj Lasix 40mg iv/bd
Inj Pan 40mg iv/bd
Inj Zofer 4mg iv/od
Tab shelcal po/od
Tab orofer po/od
Tab nodosis 550mg po/bd
Monitor vitals
Inj erythropoietin 4000iu weekly once sc
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