case 28 60 M with b/l lower limb swelling ,decreased Urine output

Doa 18/7/24

Dod 24/7/24

Diagnosis

AKI ON CKD SECONDARY TO CELLULITIS OF RIGHT LEG

K/c/o DM2 SINCE 6 YEARS

K/C/O HTN SINCE 4 YEARS

Case History and Clinical Findings

COMPLAINTS OF ANURIA SINCE 1 DAY

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 5 YEARS AGO THEN HE DEVELOPED

BILATERAL LOWER LIMB SWELLING AND WENT TO HOSPITAL AND WAS DIAGNOSED OF

HAVING CKD. SINCE THEN HE IS ON CONSERVATIVE MANAGEMENT.

4 DAYS AGO PATIENT HAD H/O TRAUMA DUE TO FALL ON RIGHT LOWER LIMB

H/O DECREASED URINE OUTPUT SINCE 1 DAY

NO H/O FEVER, BURNING ICTURITION, HEMATURIA, PYREXIA, CONVULSIONS

NO H/O NSAIDS OVERUSE

PAST HISTORY:

K/C/O DM2 SINCE 6 YEARS

K/C/O HTN SINCE 4 YEARS NOT USING MEDICATION

N/K/C/O CAD, CVA, TB, EPILEPSY

PERSONAL HISTORY

MIXED DIET

REDUCED APPETITE

NO ADDICTIONS/ ALLERGIES

FAMILY HISTORY : NOT SIGNIFICANT

GENERAL EXAMINATION:

PALLOR PRESENT

NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY

TEMPERATURE: AFEBRILE

PULSE RATE: 85BPM

RESPIRATORY RATE: 18

BP: 120/50MMHG

SPO2: 98%

GRBS: 78 MG%

SYSTEMIC EXAMINATION

CVS: S1, S2 HEARD, NO MURMURS

RS: BAE PRESENT, CREPTS PRESENT

ABDOMEN: OBESE, NON TENDER, NO PALPABLE ORGANOMEGALY

CNS: NO FOCAL NEUROLOGICAL DEFICIT NOTED

GENERAL SURGERY REFERRAL DONE ON 18/7/24

ADVISED: MGSO4 DRESSING DAILY

EUSOL DRESSING DAILY

PROTEIN RICH DIET

RIGHT LIMB ELEVATION

Investigation

RFT 18-07-2024 03:07:PMUREA 122 mg/dlCREATININE 6.7 mg/dlURIC ACID 6.5 mmol/LCALCIUM

9.2 mg/dlPHOSPHOROUS 3.2 mg/dlSODIUM 135 mmol/LPOTASSIUM 3.0 mmol/L.CHLORIDE 99

mmol/L

Anti HCV Antibodies - RAPID 18-07-2024 03:18:PM Non Reactive

HIV 1/2 Rapid Test 18/7/24 Non Reactive

HBsAg-RAPID 18-07-2024 03:18:PM Negative

LIVER FUNCTION TEST (LFT) 18-07-2024 04:01:PMTotal Bilurubin 1.32 mg/dlDirect Bilurubin 0.44

mg/dlSGOT(AST) 13 IU/LSGPT(ALT) 10 IU/LALKALINE PHOSPHATASE 294 IU/LTOTAL

PROTEINS 4.9 gm/dlALBUMIN 2.37 gm/dlA/G RATIO 0.94SERUM ELECTROLYTES (Na, K, C l) 18-

07-2024 06:54:PMSODIUM 136 mmol/LPOTASSIUM 3.0 mmol/LCHLORIDE 99 mmol/L

RFT 18-07-2024 11:41:PMUREA 111 mg/dlCREATININE 5.7 mg/dlURIC ACID 5.8 mmol/LCALCIUM

9.2 mg/dlPHOSPHOROUS 3.0 mg/dlSODIUM 136 mmol/LPOTASSIUM 3.2 mmol/L.CHLORIDE 99

mmol/L

RFT 19-07-2024 11:33:PMUREA 131 mg/dlCREATININE 6.8 mg/dlURIC ACID 6.7 mmol/LCALCIUM

9.7 mg/dlPHOSPHOROUS 3.4 mg/dlSODIUM 136 mmol/LPOTASSIUM 3.3 mmol/L.CHLORIDE 102

mmol/L

RFT 20-07-2024 10:58:PMUREA 90 mg/dlCREATININE 4.9 mg/dlURIC ACID 4.7 mmol/LCALCIUM

10.0 mg/dlPHOSPHOROUS 3.6 mg/dlSODIUM 136 mmol/LPOTASSIUM 3.4 mmol/L.CHLORIDE 102

mmol/LRFT 21-07-2024 11:42:PMUREA 102 mg/dlCREATININE 4.7 mg/dlURIC ACID 5.0

mmol/LCALCIUM 10.1 mg/dlPHOSPHOROUS 4.0 mg/dlSODIUM 136 mmol/LPOTASSIUM 3.0

mmol/L.CHLORIDE 102 mmol/L

RFT 23-07-2024 06:32:AMUREA 73 mg/dlCREATININE 3.6 mg/dlURIC ACID 3.7 mmol/LCALCIUM

9.9 mg/dlPHOSPHOROUS 3.9 mg/dlSODIUM 135 mmol/LPOTASSIUM 3.4 mmol/L.CHLORIDE 105

mmol/L

Blood Lactate ON 22/7/24 14.2 mg/dl

HEMOGRAM ON 19/7

HAEMOGLOBIN 7.8 gm/dl 13.0 - 17.0 ColorimetricTOTAL COUNT 11,170 cells/cumm 4000 - 10000

ImpedenceNEUTROPHILS 87 % 40 - 80 Light MicroscopyLYMPHOCYTES 06 % 20 - 40 Light

MicroscopyEOSINOPHILS 01 % 01 - 06 Light MicroscopyMONOCYTES 06 % 02 - 10 Light

MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 21.2 vol % 40 - 50 CalculationM C V 91.8 fl

83 - 101 CalculationM C H 33.8 pg 27 - 32 CalculationM C H C 36.8 % 31.5 - 34.5 CalculationRDW-

CV 15.2 % 11.6 - 14.0 HistogramRDW-SD 51.0 fl 39.0-46.0 HistogramRBC COUNT 2.31

millions/cumm 4.5 - 5.5 ImpedencePLATELET COUNT 1.3 lakhs/cu.mm 1.5-4.1

ImpedenceSMEARRBC Normocytic normochromic Light MicroscopyWBC increased counts with

absoluteneutrophiliaLight MicroscopyPLATELETS decreased counts on smear Light

MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION Normocytic

normochromic anemiawith neutrophilic leucocytosis andmild thrombocytopenia

HEMOGRAM ON 20/7

HAEMOGLOBIN 8.0 gm/dl 13.0 - 17.0 ColorimetricTOTAL COUNT 12,000 cells/cumm 4000 - 10000

ImpedenceNEUTROPHILS 85 % 40 - 80 Light MicroscopyLYMPHOCYTES 08 % 20 - 40 Light

MicroscopyEOSINOPHILS 01 % 01 - 06 Light MicroscopyMONOCYTES 06 % 02 - 10 Light

MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 22.8 vol % 40 - 50 CalculationM C V 95.4 fl

83 - 101 CalculationM C H 33.5 pg 27 - 32 CalculationM C H C 35.1 % 31.5 - 34.5 CalculationRDW-

CV 15.4 % 11.6 - 14.0 HistogramRDW-SD 53.5 fl 39.0-46.0 HistogramRBC COUNT 2.39

millions/cumm 4.5 - 5.5 ImpedencePLATELET COUNT 1.3 lakhs/cu.mm 1.5-4.1

ImpedenceSMEARRBC Normocytic normochromic Light MicroscopyWBC Increased counts on smear

Light MicroscopyPLATELETS Inadeqaute Light MicroscopyHEMOPARASITES No hemoparasites

seen Light MicroscopyIMPRESSION Normocytic normochromic anemiawith neutrophilic leukocytosis

andthrombocytopenia FBS 105 mg/dl

PLBS 156 mg/dl HBA1C 5.6%

HEMOGRAM ON 21/7

HAEMOGLOBIN 7.5 gm/dl 13.0 - 17.0 ColorimetricTOTAL COUNT 8,400 cells/cumm 4000 - 10000

ImpedenceNEUTROPHILS 80 % 40 - 80 Light MicroscopyLYMPHOCYTES 09 % 20 - 40 Light

MicroscopyEOSINOPHILS 02 % 01 - 06 Light MicroscopyMONOCYTES 09 % 02 - 10 Light

MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 21.8 vol % 40 - 50 CalculationM C V 94.5 fl

83 - 101 CalculationM C H 32.7 pg 27 - 32 CalculationM C H C 34.7 % 31.5 - 34.5 CalculationRDW-

CV 15.6 % 11.6 - 14.0 HistogramRDW-SD 54.0 fl 39.0-46.0 HistogramRBC COUNT 2.30

millions/cumm 4.5 - 5.5 ImpedencePLATELET COUNT 1.5 lakhs/cu.mm 1.5-4.1

ImpedenceSMEARRBC Normocytic normochromic Light MicroscopyWBC With in normal limits Light

MicroscopyPLATELETS Adeqaute Light MicroscopyHEMOPARASITES No hemoparasites seen Light

MicroscopyIMPRESSION Normocytic normochromic anemia

HEMOGRAM ON 23/7

HAEMOGLOBIN 7.1 gm/dl 13.0 - 17.0 ColorimetricTOTAL COUNT 8,900 cells/cumm 4000 - 10000

ImpedenceNEUTROPHILS 77 % 40 - 80 Light MicroscopyLYMPHOCYTES 10 % 20 - 40 Light

MicroscopyEOSINOPHILS 03 % 01 - 06 Light MicroscopyMONOCYTES 10 % 02 - 10 Light

MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 20.4 vol % 40 - 50 CalculationM C V 94.9 fl

83 - 101 CalculationM C H 33.2 pg 27 - 32 CalculationM C H C 35.0 % 31.5 - 34.5 CalculationRDW-

CV 15.8 % 11.6 - 14.0 HistogramRDW-SD 54.8 fl 39.0-46.0 HistogramRBC COUNT 2.5

millions/cumm 4.5 - 5.5 ImpedencePLATELET COUNT 1.40 lakhs/cu.mm 1.5-4.1

ImpedenceSMEARRBC Normocytic normochromic Light MicroscopyWBC With in normal limits Light

MicroscopyPLATELETS thrombocytophenia Light MicroscopyHEMOPARASITES No hemoparasites

seen Light MicroscopyIMPRESSION Normocytic normochromic anemiawith thrombocytophenia

WOUND SWAB CULTURE AND SENSITIVITY SENT ON 22/7/24

OCCASIONAL RBC, PUS CELLS, MANY GRAM NEGATIVE BACILLI SEEN

CITROBACTER SPECIES ISOLATED

RESISTENT TO AMOXYCLAVEM, GENTAMYCIN, CEFURAXIME, CEFTAZIDIME,CLAVULANIC

ACID, PIPERACILLIN, MEROPENEM

INTERMEDIATE TO CIPROFLOXACIN

RESISTENT TO AMIKACIN

ECG: NORMAL SINUS RHYTHM

USG ABDOMEN PELVIS DONE ON 18/7/24

RIGHT KIDNEY- 8X4.1CM NORMAL SIZE, INCREASD ECHOGENICITY

LEFT KIDNEY- 8.1X3.9CM NORMAL SIZE, INCREASD ECHOGENICITY

FINDINGS: 30X25MM CYST NOTED IN UPPER POLE OF RIGHT KIDNEY

IMPRESSION:

GRADE II RPD CHANGES IN BILATERAL KIDNEYS

RIGHT KIDNEY CORTICAL CYST

2D ECHO DONE ON 19/7/24

EF-56%

IMPRESSION: MILD MR/AR/TR WITH PAH

NO RWMA, MILD AS, NO PAS, CALCIFIED AV

GOOD LV SYSTOLIC FUNCTION

GRADE I DIASTOLIC DYSFUNTION, NO LV CLOTS

Treatment Given(Enter only Generic Name)

FLUID RESTRICTION <1.5 LITER/ DAY

SALT RESTRICTION <2GM/DAY

INJ. MONOCEF LS IV/BD

INJ NEOMOL IV

INJ PANTOP 40MG IV/OD

INJ LINEZOLID 600MG IV/BD

TAB LASIX 20MG PO/OD

TAB OROFER XT PO/OD

TAB SHELCAL LT PO/OD

TAB TELMA 40MG PO/OD

TAB NODOSIS 500MG PO/BD

SYP POTKLOR 15ML PO/TID IN ONE GLASS OF WATER

OINTMENT ZYTEE GEL

Advice at Discharge

FLUID RESTRICTION <1.5 LITER/ DAY

SALT RESTRICTION <2GM/DAY

TAB PANTOP 40MG PO/OD 1--0--0 X 3 DAYS

TAB TELMA 40MG PO/OD

TAB LASIX 20MG PO/BD

TAB OROFER XT PO/OD

TAB SHELCAL CT PO/OD

TAB NODOSIS 500MG PO/BD

TAB LINEZOLID 600MG PO/BD X 4 DAYS

SYP POTKLOR 15ML PO/TID IN ONE GLASS OF WATER X 3 DAYS

lost follow up