A CASE OF AKI UNDER EVALUATION
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ECG:
A 65 year old female who is a homemaker and a resident of nuthanakal came to op with complaints of pain abdomen since 4 days and SOB since 2 days.she also complaints of reduced urine output since 2 days.
She has history of fever since 5 days which is low grade associated with chills which was intermittent and has no diurnal variations.
No h/o nausea, vomiting.
No h/o burning micturition.
No h/o hematuria/frothy urine.
No h/o cough,cold.
She is k/c/o HTN since 6 years on T.LOSARTAN 50Mg+T.HYDROCHLOROTHIAZIDE 12.5 Mg
Not a k/c/o DM, TB,Asthma, Epilepsy
She has normal appetite,takes mixed diet, regular bowel and bladder movements,no addictions.
O/E:
Patient is conscious, coherent and cooperative.
Bilateral Pedal edema is present
No pallor, icterus, cyanosis, clubbing, lymphadenopathy.
Vitals:
Temp-98.5 degrees F
PR-81BPM
RR-20 CPM
BP-120/70 mm Hg
Spo2:97% at room air
GRBS-151 Mg%
RS: bilateral air entry+;clear
CVS: S1S2+
P/A: soft, non tender
CNS: NFD
Provisional diagnosis:
AKI under evaluation
INVESTIGATIONS:
Hemogram:
Hb-12.0
Tlc-15,100
Ptc-2.31 lakhs
Normocytic, normochromic
ABG:
pH-7.281
Pco2:9.8
Po2:117
So2:96.4%
RBS:145
Urea-128
Creatinine-2.7
Na-136
K-4.5
Cl-94
LFT:
TB-1.31
DB-0.50
AST-112
ALT-74
ALP-445
TP-5.5
Albumin-2.2
A/G- 0.69
X-ray:
TREATMENT:
1) IVF-2 NS,1 RL@75 ML/HR
2)INJ.PAN 40 MG IV/OD
3)INJ.ZOFER 4MG IV SOS
4)INJ.LASIX 40 MG IV/BD
5)INJ.NEOMOL 1GM IV/SOS
6)INJ SODIUM BICARBONATE 50 MEQ DIRECT IV F/B 100 MEQ IN 100ML NS OVER 1 HR
7)T.DOLO 650MG PO/QID
8)INJ.CEFTRIAXONE 1GM IV/BD
9)MONITOR VITALS AND INFORM SOS
11/11/21:
S:fever reduced
O:on examination patient is conscious, coherent and cooperative
BP:120/80 mm Hg
PR:82 bpm
RR:18 cpm
CVS: S1S2+
RS:BAE+
GRBS:115 MG/DL
A:AKI on CKD
P:
TREATMENT:
1) IVF-2 NS,1 RL@75 ML/HR
2)INJ.PAN 40 MG IV/OD
3)INJ.ZOFER 4MG IV SOS
4)INJ.LASIX 40 MG IV/BD
5)INJ.NEOMOL 1GM IV/SOS
6)INJ SODIUM BICARBONATE 50 MEQ DIRECT IV F/B 100 MEQ IN 100ML NS OVER 1 HR
7)T.DOLO 650MG PO/QID
8)INJ.CEFTRIAXONE 1GM IV/BD
9)MONITOR VITALS AND INFORM SOS
12/11/21:
OPTHALMOLOGY REFERRAL'
S:c/o cough, fine tremors of hand
O:on examination patient is conscious, coherent and cooperative
BP:120/70 mm Hg
PR:80 bpm
RR:18 cpm
CVS: S1S2+
RS:BAE+
A:AKI on CKD
P:
TREATMENT:
1) IVF-2 NS,1 RL@75 ML/HR
2)INJ.PAN 40 MG IV/OD
3)INJ.ZOFER 4MG IV SOS
4)INJ.LASIX 40 MG IV/BD
5)INJ.NEOMOL 1GM IV/SOS
6)INJ SODIUM BICARBONATE 50 MEQ DIRECT IV F/B 100 MEQ IN 100ML NS OVER 1 HR
7)T.DOLO 650MG PO/QID
8)INJ.CEFTRIAXONE 1GM IV/BD
9)T.AZITHROMYCIN 500 MG PO/OD
10)MONITOR VITALS AND INFORM SOS
13/11/21
S:c/o cough,one fever spike last night,nausea+,one episode of vomiting
O:on examination patient is conscious, coherent and cooperative
BP:120/70 mm Hg
PR:80 bpm
RR:18 cpm
CVS: S1S2+
RS:b/l infrascapular crepts
GRBS:97 MG/DL
A:B/L right lower lobe consolidation,AKI on CKD
P:
treatment:
1)oral fluids upto 2 literes/day
2)INJ.CEFTRIAXONE 1GM IV/BD
3)INJ.PAN 40 MG IV/OD
4)INJ.ZOFER 4 MG IV/TID
5)INJ.LASIX 40MG IV/BD
6)INJ.NEOMOL 1GM IV/SOS(IF TEMP>102)
7)T.AZITHROMYCIN 500 MG PO/OD
8)SYP.SUCRALFATE 10 ML PO/TID
9)NEB WITH DUOLIN TID,BUDECORT BD
10) T.MONTELEUKAST-LC PO/HS
11)INJ.METACLOPRAMIDE IV/OD
12)STRICT I/O CHARTING
13)SYP.ASCORYL-D PO/BD
14) MONITOR VITALS AND INFORM SOS
15) TEMPERATURE MONITORING 4TH HOURLY
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