ICU Bed 1

 This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

Thursday,March 10th

A 24year old male came with decreased urine output ,sob,pedal edema

B.Sushma ,9th semester

Roll no.154

March 10th,2022

A CASE DISCUSSION ON DECREASED URINE OUTPUT,SOB,PEDAL EDEMA

I've 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 a diagnosis and treatment plan.

CASE PRESENTATION:

A 24yr old male, who is a labourer presented to casuality on 9thmarch2022 with

CHEIF COMPLAINTS of

Decreased urine output since 10 days

Shortness of breath since 10 days 

Pedal edema since 10 days 

Fever since 10 days

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic till 5yrs of age then he developed history of anuria at 5yrs of age and there was suprapubic bulge seen  for which medical intervention was done (foleys catheter)

At 21yrs of age  he developed decreased urine output for which he went to a local hospital and scan was done which revealed hydronephrosis .

10 days back he had a trauma to left little finger , And history of thorn prick to dorsum of right foot  there was a history of pus discharge in right foot and left little finger is gangrenous.

10 days back he developed shortness  of breath which was insidious in onset and gradually progressive (grade 4 ) aggravated on walking relieved on medication .

Pedal edema since 10 days which was extending till ankle 

Fever since 10 days which was intermittent , not associated with chills and rigor  .

PAST HISTORY 

Not a K/c/o  DM , HTN , asthma , epilepsy , TB ,CAD

No past surgical history 

No previous blood transfusions

PERSONAL HISTORY 

Appetite - decreased

Diet - vegetarian

Bowel and bladder movements - bowel movements are regular and decreased urine output

Addictions - no addictions

FAMILY HISTORY

No significant family history .

GENERAL EXAMINATION :

Patient is conscious ,  coherant ,cooperative

pallor present

No icterus , cyanosis , lymphadenopathy, edema 

On Examination

Afebrile

Bp:130/80 mm hg 

PR ; 88bpm regular

Cvs : s1 s2 +

Rs : BAE +

P/A: soft , non tender

Investigations :

RFT:

On 9/03/22

Blood urea: 175 mg/dl

Serum creatinine : 9.3 mg/dl

Sodium : 144 meq/l

Potassium :3.6 meq/l

Chloride:106 meq/ l

On 10/03/2022

On 11/03/2022

On 13/03/2022

ABG:

On 9/03/22

PH :7.3mmhg

Pco2:7.8mm hg

Po2:123 mmhg

St. Hco3:5.8mmol/L

On 10/03/2022

On 13/03/2022

Hemogram

On 9/3/2022

On 10/03/2022

On 11/03/2022

USG

ECG

X-ray chest

Arterial doppler of upper limb

X-ray of left hand

X-ray of right foot

PROVISIONAL DIAGNOSIS:

Acute kidney injury secondary to right lower limb cellulitis

TREATMENT :

Day 0

1.Inj piptaz 4.5 gm IV STAT F/B inj . Piptaz 2.25 gm IV / QID 

2.inj clindamycin 600 mg /IV / tid

3.inj pan 40 mg IV /od

4.Tab nodosis 500 mg po/bd 

5.Tab shellac 550 mg  po / od

6.IVF NS and RL @ 100 ml / hr 

7.Inj lasix 40 mg IV / bd if bp is more than 110 mm of hg 

8.Tab alpha  - D3

11/03/2022

Icu bed no 1

SOAP NOTES

A 24 YEAR OLD MALE

SUBJECTIVE

Decreased shortness of breath compared to yesterday

OBJECTIVE

Pt is c/c/c

Pallor +

Malnutrition +

Dehydration +

No cyanosis, Icterus,Lymphadenopathy 

Temp: afebrile

BP: 120/70 mm hg

PR: 86 bpm

CVS: s1, s2 heard

CNS: NAD

RS: BAE+

P/A: soft , non tender

ASSESSMENT-

Chronic kidney disease secondary to  hydroureteronephrosis

PLAN OF TREATMENT-

Day 2

1.IV fluids (NS)  30 ml/ hr

2.Inj piptaz 2.25 gm

3.Inj clindamycin 300 mg  Iv / tid

4.Inj pan 40 mg iv od

5.Inj lasix 40 mg  iv bd

6.Tab nodosis  500 mg bd

7.Tab shellac 500 mg od

8.Cap bio D3 0.25 mg 

9.Monitor vitals