A 15 yr old male patient with AKI

 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 patient's clinical problems with collective current best evidence based inputs

Date of admission:8/11/2021

CHIEFCOMPLAINT:

A 15 yr old male ,studying 9 th class came to the casuality with chest pain,discomfort in breathing while lying down since 3 days

HISTORY OF PRESENT ILLNESS:

Pt was apparently asymptomatic 2 months back then he complains of vomitings 2 - 3 episodes daily associated with food particles not associated with blood ,for around 1 month 

H/O fever 2 months back associated with chills relieved with medication by 2 days 

Incidentally patient found to have urea 62 mg/dlCreatinine 8.3 went to Hyderabad. Within 1 day urea has raised to 135mg/dl and creatinine 10.7 

And started him on dialysis.5 sessions of Hemodialysis done in Hyderabad.Since then he was on hemodialysis. pt C/O SOB since 3 days during evening times which is aggravating on supine position,associated with paroxysmal nocturnal dyspnoe.

C/O chest pain on inspiration,dragging type only during episode of sob.He is also K/C/O facial puffiness.No C/O syncope attack

Previous reports 





PAST HISTORY:

Hypertensive since 1 month and is on Tab.AMLONG 5 mg 

History of 3 transfusions 1 month back 

Not a K/C/O DM ,Asthma ,epilepsy ,thyroid disorders . 

Family History :

No H/O renal problems in their whole family.

His paternal grandfather is diabetic and hypertensive

Personal History:

Diet - mixed 

Appetite - normal 

Sleep - adequate 

Bowel movements : regular 

Bladder movements : regular 

No history of alcohol consumption or smoking history 

General Examination:

Patient is conscious, coherent , cooperative

Pallor -present 

Icterus -absent 

Clubbing-absent 

Cyanosis -absent 

Generalised Lymphadenopathy-absent 

Pedal Edema -absent 

On examination:

Vitals: 

On day 1:

Temperature : 98.6°F

BP: 140/90 mm Hg in right upper arm in supine position

PR: 76 bpm

RR: 20 cycles per minute

Spo2: 88% on room air

96% at 4 litres of O2

On day-2:

Temperature : afebrile 

Pulse rate : 96 bpm

Respiratory rate : 24 cycles /min 

BP : 140/100 mm of Hg 

SpO2 : 86 % at Room air .

GRBS : 121 mg%

Systemic Examination: 

CVS: S1,S2 heard no murmurs

RESPIRATORY SYSTEM:Bilateral Air Entry - present 

Bilateral crepitations heard at IAA and ISA.

No wheeze

Per Abdomen: 

Soft ,non tender 

Bowel sounds + 

CNS:

NAD

Bilateral grade 1 rpd changes








Provisional diagnosis : 


Acute Kidney Injury (AKI)


Treatment :


1. Tab Lasix 40mg po/ BID


2. Neb with duolin ,budecort -8th hourly 


3.Tab .Zoffer - 4mg po /TID


4. Tab .Nodosis -500mg po /BID


5. O2 inhalation to maintain SpO2 


6. Tab orofer AT po /BID


7.STRICT I/O CHARTING 


8. BP ,PR,RR CHARTING


9. Tab Rantac 150 mg po /OID

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