Case 48 71 female with decreased urine output since 10 days

Diagnosis

1. STAGE IV CHRONIC KIDNEY DISEASE SECONDARY TO DIABETIC NEPHROPATHY

2. ACUTE PULMONARY EDEMA (RESOLVED)

3. HEART FAILURE WITH MID RANGE EJECTION FRACTION

4. ACUTE ON CKD SECONDARY TO UTI SECONDARY TO ? TRANSISITIONAL CELL

CARCINOMA OF BLADDER

5. K/C/O LEFT BREAST CARCINOMA S/P LEFT MASTETCTOMY WITH CRT 30 YEARS AGO

6. K/C/O ACS - CAD - TVD S/P CABG 8 YEARS AGO

7. HYPOTHYROIDISM; TYPE II DIABETIS MELLITUS; HYPERTENSION

Case History and Clinical Findings

PRESENTING COMPLAINTS:

A 70 YEAR FEMALE HOME MAKER PRESENTED TO NEPHROLOGY OPD WITH COMPLAINTS

OF DECREASED URINARY OUTPUT SINCE 10 DAYS, ANURIA SINCE 1 DAY; GENERALIZED

WEAKNESS SINCE 10 DAYS; NAUSEA AND VOMITING SINCE 3 DAYS ( RESOLVED ON

MEDICATIONS); DECREASED APPETITE AND CONSTIPATION SINCE 3 DAYS.

HOPI

A 70 YEAR FEMALE PRESENTED WITH ABOVE MENTIONED COMPLAINTS; UPON ADMISSION

VITALS ARE PR 98 BPM, BP 90/60 mmHg, RR 26 CPM; SpO2 98% 6 LIT OF O2;GRBS 124

MG/DL; INITIALLY FLUID CHALLENGE WITH FUROSEMIDE WAS GIVEN, PATIENT HAS

RESPONDED TO FUROSEMIDE STRESS TEST; BED SIDE SCREENING ECHO WAS DONE

WHICH SHOWED GLOBAL HYPOKINESIA, MILD LV DYSFUNCTION, EF 38%. PATIENT WAS

STARTED ON DIURETICS AND INONTROPIC SUPPORT, RATE CONTROLLER,

ANTIPLATELETS AND OTHER SUPPORTIVE MEDICATIONS. DURING THE COURSE IN THE

HOSPITAL THE CONDITION OF THE PATIENT HAS GRADUALLY IMPROVED AND WEANED

OFF FROM THE INOTROPIC SUPPORT AND OXYGENATION.

GENERAL EXAMINATION

PT IS C/C/C

BP-140/80MMHD

PR-86BPM

SPO2-99

RR-18CPM

SYSTEMIC EXAMINATION

CVS-S1S2+

RS-NVBS

CNS-NFND

P/A

SOFT ,NT

NCCT KUB (FINDINGS : RIGHT MODERATE TO SEVERE HYDRONEPHROSIS ,DILATED RIGHT

URETER UP TO MID PORTION WITH MILD THINCKENING AND IRREGULERITY OF MID/DISTAL

PORTION OF RIGHT URETER -TO RULE OUT STRUCTURE AND TRANSTIONAL CELL

CARCINOMA

ADVISED FOR BIOPSY UNDER KUB

Investigation

COMPLETE URINE EXAMINATION (CUE) 11-01-2024 05:25:PM

COLOUR

Pale yellowAPPEARANCECloudy

REACTION

Acidic

SP.GRAVITY

1.010

ALBUMIN

++

SUGAR

Nil

BILE SALTS

Nil

BILE PIGMENTS

Nil

PUS CELLS

6-10

EPITHELIAL CELLS

3-4

RED BLOOD CELLS

5-8

CRYSTALS

Nil

CASTS

Nil

AMORPHOUS DEPOSITS

Absent

OTHERS

Nil

RFT 11-01-2024 05:25:PM

UREA

88 mg/dl

CREATININE

5.5 mg/dl

SODIUM

128 mEq/L

POTASSIUM

4.5 mEq/L

CHLORIDE

96 mEq/L

HBsAg-RAPID11-01-2024 05:25:PM

Negative

Anti HCV Antibodies - RAPID11-01-2024 05:25:PM

Non Reactive

ABG 11-01-2024 05:27:PM

PH

7.35

PCO2

40.8

PO2

34.0

HCO3

22.4

St.HCO3

22.4

BEB

-2.2

BEecf

-2.2

TCO2

51.1

O2 Sat

72.4

O2 Count

3.7

BLOOD UREA12-01-2024 01:19:AM

85 mg/dl

SERUM CREATININE12-01-2024 01:19:AM

5.4 mg/dl

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 12-01-2024 01:19:AM

SODIUM

128 mEq/L

POTASSIUM

4.2 mEq/L

CHLORIDE 91 mEq/L

CALCIUM IONIZED

1.14 mmol/L

SERUM CREATININE13-01-2024 12:42:AM

FBS 148 mg/dl

Plbs 180 mg/dl

Hba1c 6.6%

5.6 mg/dl

SODIUM

132 mEq/L

POTASSIUM

4.1 mEq/L

CHLORIDE

96 mEq/L

CALCIUM IONIZED1.05 mmol/L

11/1/24

HAEMOGRAM :

HB-8.2

PCV-24.5

TLC-25000

RBC-2.87

PL COUNT-1.52

12/1/24

HAEMOGRAM :

HB-7.7

PCV-22.1

TLC-22300

RBC-2.60

PL COUNT-1.50

13/1/24

HAEMOGRAM :

HB-8.0

PCV-23.1

TLC-26600

RBC-2.7

PL COUNT-1.50

14/1/24

HAEMOGRAM :

HB-8.4

PCV-24.5

TLC-22200

RBC-2.7

PL COUNT-1.50

Treatment Given(Enter only Generic Name)

FLUID RESTRICTION <1.5LT/DAY

SALT RESTRICTION <2 GRAMS/DAY

INJ.DOBUTAMINE 250MG 5ML+ 45ML NS AT 5 MCG/KG/MIN

TAB.TORSEMIDE 20MG/PO/BD 8AM---X--4PM

TAB.THYRONORM 50MCG/PO/OD AT 6AM

TAB.ECOSPRIN-AV 75/10/PO/HS AT 8PM

INJ.MEROPENEM 500MG/IV/OD

TAB.OFLOXACIN 300MG/PO/OD

TAB.ISOSORBIDE 5MG/PO/OD

TAB.NICORANDIL 10MG/PO/OD

TAB.MET-XL 12.5MG/PO/SOS

SYP.CREMAFFIN PLUS 15ML/PO/TID

SYP.ASCORYL LS 15ML/PO/TID

INJ. HUMAN ACTRAPID INSULIN/SC/TID

8AM--1PM--8PM

TAB.METALAZONE 5MG/PO/BD AT 11AM

Advice at Discharge

REFER TO HIGHER CENTER:

THE PATIENT AND THEIR ATTENDERS HAS BEEN EXPLAINED REGARDING THE CONDITION

OF THE PATIENT ,HAS URINARY TRACT INFECTION SECONDARY TO OBSTRUCTION

LEADING TO ACUTE ON CKD ;HAERT FAILURE WITH MID RANGE EJECTION FRACTION AND

NEED FOR CYSCTOSCOPIC GAIDED BIOPSY OF URETERIC AND BLADDER LESION IN THER

OWN UNDERSTANDABLE LANGUAGE ,SO THE PATIENT HAS BEEN REFERRED TO HIGHER

CENTRE FOR FURTHER MANANGEMENT

Follow up -Irregular

Non compliant to diet and medication

Home death