case 7

Case 7 - 66 year old female 
DOA-1/06/24
DOD-7/06/24
CKD DURATION -not known

DIAGNOSIS 

AKI ON CKD 
HEART FAILURE WITH PRESERVED EJECTION FRACTION SECONDARY TO CAD ? SEPTIC SHOCK -UROSEPSIS ? CARDIOGENIC SHOCK K/C/O CAD -S/P . PTCA- LAD,LCX K/C/O HYPERTENSION SINCE 10 YEARS K/C/O TYPE 2 DM SINCE 10 YEARS 


Case History and Clinical Findings
PATIENT CAME WITH COMPLAINTS OF FEVER SINCE 2 DAYS AND SHORTNESS OF BREATH SINCE TODAY MORNING.

HOPI:
 PATIENT WAS APPARENTLY ASYMPTOMATIC UNTIL TWO DAYS BACK, THEN DEVELOPED FEVER OF LOW GRADE ASSOCIATED WITH CHILLS , RELIEVED WITH MEDICATION AT LOCAL RMP. COMPLAINTS OF SHORTNESS OF BREATH SINCE TODAY MORNING ASSOCIATED WITH SWEATING NOT ASSOCIATED WITH CHEST PAIN, PALPITATIONS
NO H/O PEDAL EDEMA, DECREASED URINE OUTPUT, FACIAL PUFFINESS. NO H/O PAIN ABDOMEN , ABDOMINAL BLOATING SENSATION NO H/O COUGH, COLD, ALLERGIC RHINITIS, SNEEZED NO H/O NAUSEA, VOMITINGS, GIDDINESS, SYNCOPE.

 PAST HISTORY :
K/C/O HYPERTENSION SINCE 10 YEARS, ON TAB. MET-XL 50 mg PO/OD
K/C/O DM SINCE 10 YEARS , ON TAB. METFORMIN 500 mg + GLIMIPERIDE 1 mg + VOGLIBOSE
K/C/O CAD SINCE 1 YEAR , S/P STENT TO LAD, LCP
FAMILY HISTORY - NOT SIGNIFICANT
PERSONAL HISTORY :-
MIXED DIET
APPETITE - NORMAL
REGULAR BOWEL MOVEMENTS
GENERAL EXAMINATION :
PATIENT IS CONSCIOUS, COHERENT AND COOPERATIVE
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY
AT ADMISSION
TEMP:98.4F
PR:96 BPM
RR:38CPM
BP:110/60mmHg
SPO2:98@RA 2L 02
GRBS : 195 mg/dL
SYSTEMIC EXAMINATION
CVS:S1 S2+ , NO MURMURS
RS:BAE+, NVBS+
P/A- SOFT ,NON TENDER, NO ORGANOMEGALY
CNS : PATIENT IS CONSCIOUS, COHERENT AND CO-OPERATIVE AND WELL ORIENTED TO
TIME, PLACE AND PERSON
HIGHER MENTAL FUNCTIONS INTACT. NO FOCAL NEUROLOGICAL DEFICITS
REFLEXES : RIGHT LEFT
BICEPS +2 +2
TRICEPS +2 +2
SUPINATOR +1 +1
KNEE +2 +2
ANKLE - -
COURSE IN THE HOSPITAL
68 YEAR OLD FEMALE PRESENTED WITH ABOVE MENTIONED COMPLAINTS , PATIENT WAS EVALUATED CLINICALLY AND WITH APPROPRIATED INVESTIGATIONS AND WAS PROVISIONALLY DIAGNOSED AS AKI ON CKD HEART FAILURE WITH PRESERVED EJECTION FRACTION SECONDARY TO CAD ? SEPTIC SHOCK -UROSEPSIS ? CARDIOGENIC SHOCK INITIALLY INOTROPIC SUPPORT WAS GIVEN AND WAS GRADUALLY TAPERED I/V/O DERRANGED RENAL PARAMETERS. NEED FOR HEMODIALYSIS HAS BEEN EXPLAINED AFTER TAKING DUE CONSENT , RIGHT IJV CENTRAL CENTRAL CATHETERISATION WAS DONE . DURING THE HOSPITAL STAY 4 SESSIONS OF HEMODIALYSIS WAS DONE .PATIENT RECOVERED SYMPTOMATICALLY AND DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION .
ADVICED FOR AV FISTULA CONSTRUCTION


 Investigation
COMPLETE URINE EXAMINATION
ALBUMIN +++
SUGAR Nil

HB -8.4
MCV -8.1
MCH-27.9
MCHC -32.3
TLC-18000
PLT-1.5

S.iron -43
S.ferritin-210.2

PERIPHERAL SMEAR -NORMOCYTIC NORMOCHROMIC 

ABG
 PH 7.00
PCO2 13.4
PO2 118
HCO3 3.2
St.HCO3 6.3
S02-93.2

LIVER FUNCTION TEST 

Total Bilurubin 1.97 mg/dl
Direct Bilurubin 0.33 mg/dl
SGOT(AST) 21 IU/L
SGPT(ALT) 12 IU/L
ALKALINE PHOSPHATASE 146 IU/L
TOTAL PROTEINS 7.9 gm/dl
ALBUMIN 4.3 gm/dl
A/G RATIO 1.23

ABG 
PH 7.28
PCO2 25.2
PO2 43.8
HCO3 11.6
St.HCO3 13.8
O2 Sat 71.8O

RFT
 UREA 125mg/dl
CREATININE 8.2 mg/dl
URIC ACID 4.5 mmol/L
CALCIUM 10.0 mg/dl
PHOSPHOROUS 2.4 mg/dl
SODIUM 142 mmol/L
POTASSIUM 4.1 mmol/L.
CHLORIDE 102 mmol/L

USG ABDOMEN AND PELVIS-

RAISED ECHOGENECITY OF BILATERAL KIDNEYS BILATERAL RENAL CORTICAL CYSTS

 2D ECHO WAS DONE ON 1/6/24 

IMPRESSION: RWMA PRESENT
ANTERIOR , INFERIOR , LATERAL WALL HYPOKINESIA
PARADIXICAL IVS , MODERATE TR WITH PH , EF 52% , GRADE 1 DIASTOLIC DYSFUNCTION FAIR LV FUNCTION



Treatment Given(Enter only Generic Name)
 1. INJ. PIPTAZ 2.25 g IV TID
 2.INJ. PAN 40 mg IV OD 
3. INJ. ZOFER 4 mg IV TID 
4. INJ. LASIX 40 mg IV 
5. TAB. TELMA 40 mg PO/OD 
6. TAB. NODOSIS 500 mg PO/TID 
7. TAB. OROFER- XT PO/OD 
8. INJ. HAI S/C TID ( AS PER ADVICE )

INTERVENTIONS
ORAL IRON THERAPY -DAILY TAB.OROFER XT
IV IRON THERAPY -TWICE /WEEK
EPO -YES
EPO DOSING -ONCE/WEEKS
PRBC TRANSFUSED -0
ADMISSION IN ICU -0

 Advice at Discharge
TAB. TELMA 40 mg PO/OD AT 8 AM TO CONTINUE
 TAB. NODOSIS 500 mg PO/TID TO CONTINUE TAB. OROFER- XT PO/OD TO CONTINUE INJ. HAI 6 UNITS S/C TID 6U-6U-6U TAB SHELCAL -CT 500MG PO/OD
TAB LASIX 40MG PO/BD TO CONTINUE TAB ECOSPIRIN AV 75/10 PO/OD TO CONTINUE

FOLLOW UP IN 3MONTHS( later needed maintenance hemodialysis) 
HB-10.1
MCV-76.1
MCH-27.1
MCHC-31.3
TLC -7800
PLT-2.14

FOLLOW UP AT THE END OF THESIS 
-NO FOLLOW UP 

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