15 YEAR OLD MALE WITH ACUTE KIDNEY INJURY.
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan
Presenting complaints :
A 15 yr old male ,studying 9 th class came to the casuality with C/O SOB( grade 2 - 3 ) since yesterday ,orthopnea +
HOPI :
Pt was apparently asymptomatic 1 month back ,pt complains of vomitings 2 - 3 episodes daily associated with food particles not associated with blood ,for around 1 month
H/O fever 1 month back associated with chills ,relieved with medication by 2 days
InIncidentally patient found to have urea 62 mg/dl
Creatinine 8.3 went to Hyderabad within 1 day urea has raised to 135mg/dl and creatinine 10.7
And started him on dialysis .5 sessions of HD done and USG abdomen showing B/L kidneys size of 8.1 cms Grade 3 RPD changes .Since then he was on hemodialysis pt C/O SOB since yesterday evening aggravating on supine position Grade 2 - 3 ,not associated with PND
C/O chest pain ,dragging type only during episode of sob
No C/O palpitations ,syncope attack
No C/O decreased urine output ,pedal edema ,facial puffiness
Previous reports :
Past History:
Hypertensive since 1 month and is on Tab.AMLONG 5 mg
History of 3 transfusions 1 month back
Not a K/C/O DM ,Asthma ,epilepsy ,thyroid disorders
Family History :
No H/O renal problems in their whole family.
His paternal grandfather is diabetic and hypertensive
Personal History:
Diet - mixed
Appetite - normal
Sleep - adequate
Bowel movements : regular
Bladder movements : regular
No history of alcohol consumption or smoking history
General Examination:
Patient is conscious, coherent , cooperative
Pallor -present
Icterus -absent
Clubbing-absent
Cyanosis -absent
Generalised Lymphadenopathy-absent
Pedal Edema -absent
O/E:
Vitals:
On day 1
Temperature : 98.6°F
BP: 140/90 mm Hg in right upper arm in supine position
PR: 76 bpm
RR: 20 cycles per minute
Spo2: 88% on room air
96% at 4 litres of O2
Vitals :
Temperature : afebrile
Pulse rate : 96 bpm
Respiratory rate : 24 cycles /min
BP : 140/100 mm of Hg
SpO2 : 86 % at Room air .
GRBS : 121 mg%
Systemic Examination:
CVS: S1,S2 heard no murmurs
CNS: normal
RS :
Bilateral Air Entry - present
Bilateral crepitations heard at IAA and ISA.
No wheeze .
PA:
Soft ,non tender
Bowel sounds +
CNS:
NAD
Investigations :
On day 1
Tachypnoea :
ECG report :
Provisional diagnosis : Acute Kidney Injury (AKI) secondary to ? PSGN ? IgA nephropathy ? Minimal change disease
Treatment :
On day 1
1. Tab Lasix 40mg po/ BID
2. Neb with duolin ,budecort -8th hourly
3.Tab .Zoffer - 4mg po /TID
4. Tab .Nodosis -500mg po /BID
5. O2 inhalation to maintain SpO2
6. Tab orofer AT po /BID
7.STRICT I/O CHARTING
8. BP ,PR,RR CHARTING
9. Tab Rantac 150 mg po /OID
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