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55y old female with anuria

 





THIS IS AN 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT .

Manaswini
Roll no. 153
14 December , 2021

55 YEAR OLD FEMALE WITH AKI 

A 55 year old female presented to casualty with chief complain of 
- no urine output since 2 days *
- history of fever since 4 days 
- 1 episode of vomiting 
- History of frontal headache 2 month back
HOPI 
* Patient was apparently asymptomatic 1 year ago then she developed fever and weakness following a mental trauma  for which she was taken to a local RMP doctor who said her that she have kidney problem and was referred to our hospital I/v/o dialysis .
* She underwent 2 session of Dialysis in       our hospital ( urology opinion was taken Obstructive Uropathy ?? )

Past History
* History of kidney operation 1 year back       for Hydroureteronephrosis . 
* History of NSAID use for 1 year 
* 6 month back she came to our hospital with complain of pedal edema , facial puffiness  and Anuria .
* She underwent investigation and was diagnosed with urolithiasis at VUJ ( which was responsible for Anuria ) .
* After being operated her urine output           came back to normal .
* She was started on dialysis afterwards      and till now she had 2 session of Dialysis .* History of HTN since 6 month .
* Vomiting which was non projectile non       billious with food as content 
* No h/o hematuria , frothy urine 
* No h/o cold , cough , loose stools ,               burning micturition

Personal History
- Appetite decreased
- Mixed diet ( stopped taking non veg from last 3 years ) 
- Sleep adequate
- Regular ball and bladder movement
- Micturition : Anuria since 1 day 
- No known allergies  

General Examination
Patient was examined in well lit room with his consent .
Patient is conscious ,coherent and cooperative 
Patient is well oriented to time and place
Poor built and nourishment 
Pallor: present
Icterus: absent  
Clubbing : absent 
Cyanosis:absent
Lymphadenopathy: absent
Edema: present ( B/L pedal edema )
Malnutrition : present 
Mildly dehydrated
Temperature : 100 F
BP : 140/90 mmHg 
RR : 18 cpm 
SpO2 : 98 per cent at RA 

SYSTEMIC EXAMINATION
 CVS : S1 S2 + ; no murmur heard 
RS :   NVBS +
P/A :
CNS : 


REPORT 

                   ABG  08/12/21 

                          09/12/21 

            Hemogram  09/12/21 

              Hemogram  10/12/21

               Hemogram  11/12/21

                   CBC  11/12/21 

                  S. Iron  11/12/21

                     CUE  11/12/21 

                Hemogram  12/12/21 

                    CBP 13/12/21 

                 S. Iron  13/12/21

                        2D echo    11/12/21 

                USG Report  09/11/21 

        Random Blood Sugar  09/12/21 

Ramdom Blood Sugar  11/12/21 

                     RFT  09/12/21 

                      RFT  10/12/21 

                       RFT  11/12/21

               S. Uric acid  11/12/21

                    RFT  12/12/21

                   RFT  13/12/21 

                  RFT  14/12/21 

          Serum electrolytes 11/12/21 

           Phosphorus  11/12/21

                      LFT  09/12/21 

                   LFT  11/12/21 

               Anti-HCV Ab  09/12/21

            Hbs Ag Rapid  09/12/21 

                              ECG 

CLINICAL IMAGES 










08/12/21 
Inj. PAN 40 mg IV OD
Inj. LASIX 40 mg IV BD
Inj. ZOFER 40 mg IV BD 
Tab. NODOSIS 550 mg PO BD

09/12/21
Inj. PAN 40 mg IV OD 
Inj. LASIX 40 mg IV BD 
Tab. DOLO 650 mg SOS 
Tab. NODOSIS 500 mg PO BD
Tab. SHELCAL 500 mg PO OD
Inj. ZOFER 40 mg IV BD 

10/11/12
Inj. PAN 40 mg IV OD 
Inj. ZOFER 40 mg IV BD 
Inj. LASIX 40 mg IV BD 
Tab. NODOSIS 500 mg PO BD
Tab. SHELCAL 500 mg PO OD 
Tab. OROFER PO OD

11/12/21
Inj. PAN 40 mg IV OD 
Inj. ZOFER 40 mg IV BD 
Inj. LASIX 40 mg IV BD 
Tab. NODOSIS 500 mg PO BD
Tab. SHELCAL 500 mg PO OD
Tab. OROFER PO OD
Tab. PCM 650 mg PO SOS

12/12/21
Inj. PAN 40 mg IV OD 
Inj. ZOFER 40 mg IV BD 
Inj. LASIX 40 mg IV BD 
Tab. NODOSIS 500 mg PO BD
Tab. SHELCAL 500 mg PO OD
Tab. OROFER PO OD
Tab. PCM 650 mg PO SOS

13/12/21
Inj. PAN 40 mg IV OD 
Inj. ZOFER 40 mg IV BD 
Inj. LASIX 40 mg IV BD 
Tab. NODOSIS 500 mg PO BD
Tab. SHELCAL 500 mg PO OD 
Tab. OROFER PO OD
Tab. PCM 650 mg PO SOS





 





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