AKI with MODS

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Name: G Sai Manogna

Roll no 41

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.

Following is the view of my case :

CASE PRESENTATION:

A 32 year old male who is a lorry driver by occupation, resident of nalgonda has come to the casualty with the chief complaints of

• Pain abdomen since 10 days
• SOB since 10 days
• B/L pedal edema since 10 days
• Decreased urine output since yesterday

History of presenting illness:

Patient was apparently asymptomatic 10 days ago followed by he developed B/L pedal edema which is of Pitting type initially above knees and then progressed till thigh and later to abdomen followed by which he developed abdominal tightness, pain abdomen and difficulty breathing since 10 days

Pain in the abdomen was diffuse to whole abdomen and gradually increased in intensity and is squeezing type

Pain is persistent throughout the day

No history of radiation to the back

H/o of fever 10 days ago

No h/o of nausea and vomitings

There were no aggravating and relieving factors

Patient had a history of decreased urine output since 10 days and no urine output since yesterday and yesterday evening he had a history of fall due to giddiness and there is no LOC

H/O vomitings for 5 days, 5 to 6 episodes of vomitings and the content was food particles, immediately after eating anything but tolerating only fluids

JVP raised

No history of evening rise of temperature, cough, night sweats

No history suggestive of hemetemesis, melena, bleeding per rectum

No palpable mass per abdomen

Past history

Not a known case of DM, HTN, TB, epilepsy

No similar complaints in the past

Personal history

Diet- Mixed

Appetite- Decreased since 10 days

Bowel and bladder movements- Urine frequency is reduced since 3 days and patient has an history of constipation

Sleep- Adequate

Addictions-Chronic alcoholic since 15 years, consumes whisky daily(90 ml/day

Family history

No similar complaints in the family

General examination

Done after obtaining consent, in the presence of attendant with adequate exposure

Patient is conscious, coherent, cooperative and well oriented to time, place and person

Patient is well nourished and moderately built

Vitals

Temperature- Afebrile

Blood pressure- 80/60 mmHg

Pulse rate- 88 bp

Respiratory rate- 22 cpm

Local examination

Abdominal examination:

Inspection

Shape of the abdomen- Distended

Umbilicus- everted

Movements of abdominal wall- moves with respiration

Skin is smooth, shiny

No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites

Palpation

Inspectory findings are confirmed

Tenderness is present in whole of the abdomen

Guarding and rigidity present

Mild hepatosplenomegaly

Abdominal girth- 96.5 cms

Percussion

Resonant note is heard on the midline

Liver span- Not detectable

Auscultation

Bowel sounds are decreased

Investigations

Day 1 (14/10/22)

Hemogram

HB- 13.5

TC- 16400

Neutrophils- 84

Lymphocytes- 8

Eosinophils-2

Monocytes-6

Basophils-0

PCV-40.5

MCV-100.5

MCH-33.5

MCHC-33.3

RDW-CV-16

RDW-SD-56.5

RBC COUNT-4.03

PLT- 1.78

PROTHROMBIN TIME

Prothrombin time- 10-16 sec

INR- 1.85

APTT- 51 sec

BLOOD GROUPING AND TYPING

O POSITIVE

ABG

pH- 7.35

pCO2- 17.9 mmHg

pO2- 71.3 mmHg

HCO3- 9.8 mmol/L

RAPID HBsAG- NEGATIVE

RAPID HIV 1&2 - NEGATIVE

RAPID ANTI HCV ANTIBODIES- NEGATIVE

C-REACTIVE PROTEIN - 1:2 mg/dL

SERUM ELECTROLYTES

Sodium- 135 mEq/L

Potassium- 4 mEq/L

Chloride- 99 mEq/L

Calcium Ionized- 0.89 mmol/L

Urine sodium- 150

Urinary chloride- 183

Urinary potassium- 295

USG

ECG

2D ECHO

XRAY

Day 2 (15/10/22)

Hemogram

HB- 12.6

TC- 18600

Neutrophils- 90

Lymphocytes- 4

Eosinophils-2

Monocytes-4

Basophils-0

PCV-39.2

MCV-107.7

MCH-34.6

MCHC-32.1

RDW-CV-16.9

RDW-SD-63.2

RBC COUNT-3.64

PLT- 1.59

SERUM ELECTROLYTES

Sodium- 134 mEq/L

Potassium- 5.9 mEq/L

Chloride- 98 mEq/L

Calcium Ionized- 0.88 mmol/L

ABG

pH- 7.20

pCO2- 10.0 mmHg

pO2- 107 mmHg

HCO3- 3.8 mmol/L

Blood urea- 208

Serum creatinine- 5.9

Day 3 (16/10/22)

Hemogram

HB- 11.8

TC- 13700

Neutrophils- 90

Lymphocytes- 5

Eosinophils-5

Monocytes-0

Basophils-0

PCV-34.8

MCV-101.5

MCH-34.4

MCHC-33.9

RDW-CV-16.4

RDW-SD-57.8

RBC COUNT-3.43

PLT- 1.3

ABG

pH- 7.34

pCO2- 27.2 mmHg

pO2- 64.7 mmHg

HCO3- 14.3 mmol/L

RFT

Urea- 26.4

Creatinine- 7.5

Uric acid- 15.5 

Calcium- 8.0

Phosphorous- 10.0

Sodium- 135

Potassium- 4.8

Chloride- 99

PROTHROMBIN TIME

Prothrombin time- 28 sec

INR- 2.0

PROTHROMBIN TIME

Prothrombin time- 10-16 sec

INR- 1.85

APTT

APTT test- 55 sec

Provisional diagnosis- AKI with MODS

Day 4

(17/10/22)

Hemogram

Hb-11.5

TLC-8000

PLT-90000

RFT

TB-7.96

DB-4.97

TP-5.9

A/G- 8.16

Ur-230

Cr-5.9

Serum electrolytes

Na+-139

K+-4.6

Cl-101

Day 5

(18/10/22)

Hb- 10.5

TLC- 5800

PLT- 70000

RFT

TB- 8.16

DB- 5.9

AST-447

ALT- 7.59

TP- 5.9

A/G -1.26

Ur-124

Serum electrolytes

Na+ 143

K+ 3.7

Cl 103

Day 6 

(19/10/22)

Hemogram

Hb- 11.9

TLC-6500

PLT-64000

RFT

Ur- 116

Cr- 2.8

Uric acid- 8.4

Serum electrolytes

Na+ 142

K+ 3.5

Cl 99

Ca+ 7.5

PO4-5

PT- 20 sec

INR- 1.4

APTT- 39 sec

Day 7 

(20/10/22)

Hemogram

Hb- 11.2

TLC-24600

PLT-60000

RFT

Ur- 99

Cr- 2.7

Uric acid- 5

PT- 20 sec

INR- 1.4

APTT- 38 sec

LFT

TB- 13.65

DB- 10.07

SGOT- 216

SGPT- 556

ALP- 144

TP- 4.5

Alb- 2.8

LDH- 372

Day 8 

(21/10/22)

Hemogram

Hb- 10.6

TLC-22000

PLT-21000

RFT

Ur- 115

Cr- 2.5

Uric acid- 5.5

Day 9 

(22/10/22)

Hemogram

Hb- 10.5

TLC- 11900

PLT-25000

RFT

Ur- 64

Cr- 2

Uric acid- 3.8

Sodium- 139

Potassium- 3.2

Chloride- 104

Calcium- 8.8

Phosphorous- 3.4

Serum lactate- 17.0

Day 10

23/10/22

Hemogram

Hb- 11.2

TLC- 8000

PLT-43000

RFT

Ur- 66

Cr- 1.3

Uric acid- 4.5

Sodium- 142

Potassium- 3.1

Chloride- 99

Calcium- 9.1

Phosphorous- 2.9

LFT

TB- 5.21

DB- 3.68

SGOT- 41

SGPT- 221

ALP- 164

TP- 4.6

Alb- 2.59

Temperature charting

SOAP NOTES

DAY 1 (14/10/22)

S

Pain abdomen

SOB

B/L pedal edema

Decreased urine output

Cough with sputum on and off

O

Patient is conscious, coherent, cooperative

Temp - 98.6 F

BP- 80/50 mmHg'

PR- 88 bpm

RR- 18 cpm

SPO2- 94

GRBS- 128

A

AKI with MODS

P

1. Inj. pan 40 mg iv/stat

2. Inj. Lasix 40 mg iv/stat (Lasix infusion 5 mg/hr)

3. Inj. Noradrenaline 2 amp in 50 ml NS @ 4 to 6 ml/hr

4. Inj. Ceftriaxone 1gm/IV/BD

5. Syp. Lactulose 30 ml/PO/HS

6. T. Rifagut 550 mg/PO/BD

7. Abdominal girth measurement

8. BP/PR/SPO2 monitoring

9. Inj. Human actrapid insulin10 units once

DAY 2 (15/10/22)

S

Pain abdomen

SOB

B/L pedal edema

Decreased urine output

Cough with sputum on and off

O

Patient is conscious, coherent, cooperative

Temp - 98.2 F

BP- 70/40 mmHg'

PR- 80 bpm

RR- 26 cpm

SPO2- 96

GRBS- 129

A

AKI with MODS

P

1. Inj. Noradrenaline 2 amp in 50 ml NS@ 12 ml/hr to maintain SBP more than 120mmHg

2. Inj. Vasopressin 1 amp in 50 ml NS @ 2 ml/hr to maintain SBP more than 120 mmHG

3. Inj. PIPTAZ  7.5 gm iv stat

4. Inj. Zofer 4 mg/IV/BD

5. Inj. Calcium gluconate 10% ml over 10 minutes IV stat

6. Inj. Optineuron 1 amp in 100 ml NS/IV/OD

7. Inj. RANTAC 50 mg/ IV/OD

8. Syp. Lactulose 15 ml H/S

9. Nebulization 6th hrly

DAY 3 (16/10/22)

S

Pain abdomen

SOB

B/L pedal edema

Decreased urine output

Cough with sputum on and off

O

Patient is conscious, coherent, cooperative

Temp - 98.2 F

BP- 100/50 mmHg'

PR- 80 bpm

RR- 26 cpm

SPO2- 98

GRBS- 125

A

AKI with MODS

P

1. Inj. Noradrenaline 2 amp in 50 ml NS@ 12 ml/hr to maintain SBP more than 120mmHg

2. Inj. Vasopressin 1 amp in 50 ml NS @ 2 ml/hr to maintain SBP more than 120 mmHG

3. Inj. PIPTAZ  7.5 gm iv stat

4. Inj. Zofer 4 mg/IV/BD

5. Inj. Calcium gluconate 10% ml over 10 minutes IV stat

6. Inj. Optineuron 1 amp in 100 ml NS/IV/OD

7. Inj. RANTAC 50 mg/ IV/OD

8. Syp. Lactulose 15 ml H/S

9. Nebulization 6th hrly

Day 4 (17/10/22)

S

Pain abdomen

SOB

B/L pedal edema

Decreased urine output

Cough with sputum on and off

O

Patient is conscious, coherent, cooperative

Temp-98.2 F

BP- 120/70 mmHg

PR- 84 bpm

RS- BAE+

CVS- S1,S2 +

RS- BAE+

CNS- HMF+

P/A- Soft, NT

SPO2- 98%

A

AKI with MODS

?Leptospirosis

P

1. Inj. Noradrenaline 2 amp in 50 ml NS@20 ml/hr

2. Inj. Vasopressin 1 amp in 46 ml NS@ 2 ml/hr

3. Inj. Dobutamine 1 amp in 46 ml NS @ 4 ml/hr

4. Inj. PIPTAZ 2.25 gm/IV/TID

5. Inj. Zofer 4 mg/IV/BD

6. Inj. Ondansetron 1 amp in 100 ml NS/IV/OD

7. Inj. RANTAC 50 mg/IV/OD

8. Inj. VITAMIN-K 1 amp in 10 ml NS /IV/OD

9. Nebulization albutol 6th hourly

10. Syp. Lactulose 15 ml/PO/H/S

11. Tab. Doxycycline 100 mg/PO/BD

12. IVF- UO 30 ml/hr

13. BP monitoring

Day 5 (18/10/22)

S

B/L pedal edema 

O

Patient is conscious, coherent, cooperative

Temp-98.2 F

BP- 110/80 mmHg

PR- 76 bpm

RR- 25 cpm

CVS- S1,S2 +

RS- BAE+

CNS- HMF+

P/A- Soft, NT

SPO2- 93%

Abdominal girth- 93 cms

A

Renal AKI with MODS ? Leptospirosis

P

1. Inj. PIPTAZ 2.25 gm/IV/TID

2. Inj. Zofer 4 mg/IV/BD

3. Inj. Optineuron 1 amp in 100 ml NS/IV/OD

4. Inj. RANTAC 50 mg/IV/OD

5. Inj. VITAMIN-K 1 amp in 100 ml NS /IV/OD

6. Inj. Lasix 40 mg/IV/BD

7. IV fluids-UO + 30 ml/hr

8. Syp. Lactulose 15 ml/PO/H/S

9. Tab. Doxycycline 100 mg/PO/BD

10. IVF- UO 30 ml/hr

11. T. UDILIV 300 mg/PO/BD

12. Nebulization albutol 6th hourly

13. BP monitoring

14. Abdominal girth measurement daily

Day 6 (19/10/22)

S

B/L pedal edema 

O

Patient is conscious, coherent, cooperative

Temp-98.2 F

BP- 110/80 mmHg

PR- 74 bpm

RR- 24 cpm

CVS- S1,S2 +

RS- BAE+

CNS- HMF+

P/A- Soft, NT

SPO2- 94%

Abdominal girth- 92 cms

A

Renal AKI with MODS

P

1. Inj. PIPTAZ 2.25 gm IV/TID

2. Inj. Lasix 40 mg/IV/BD

3. IV fluids-UO + 30 ml/hr

4. Syp. Lactulose 15 ml/PO/H/S

5. IVF- UO 30 ml/ hour

6. Nebulization albutol 6th hourly

7. BP monitoring

8. Abdominal girth measurement daily

9. Salt restriction < 2g/dag

10. Fluid restriction < 1.5 L/day

Day 7 (20/10/22)

S

B/L pedal edema 

O

Patient is conscious, coherent, cooperative

Temp-98.2 F

BP- 100/70 mmHg

PR- 86 bpm

RR- 22 cpm

CVS- S1,S2 +

RS- BAE+

CNS- HMF+

P/A- Soft, NT

SPO2- 94%

Abdominal girth- 90 cms

A

Renal AKI with MODS

P

1. Inj. PIPTAZ 2.25 gm IV/TID

2. Inj. Lasix 40 mg/IV/BD

3. IV fluids-UO + 30 ml/hr

4. Syp. Lactulose 15 ml/PO/H/S

5. IVF- UO 30 ml/ hour

6. Nebulization albutol 6th hourly

7. BP monitoring

8. Abdominal girth measurement daily

9. Salt restriction < 2g/dag

10. Fluid restriction < 1.5 L/day

Day 8 (21/10/22)

S

B/L pedal edema 

O

Patient is conscious, coherent, cooperative

Temp-98.2 F

BP- 120/90 mmHg

PR- 80 bpm

RR- 22 cpm

CVS- S1,S2 +

RS- BAE+

CNS- HMF+

P/A- Soft, NT

SPO2- 94%

Abdominal girth- 91 cms

A

Renal AKI with MODS

P

1.Inj. Meropenem 500 mg IV BD

2.Inj. Lasix 40 mg/IV/BD

3. Inj. Zofer 4 mg IV SOS

4. Inj. Rantac 50 mg IV OD

5. Tab. UDILIV 300 mg PO BD

6. Inj. Thiamine 1 amp in 100 ml NS IV OD

7. Salt restriction < 2g/dag

8. Fluid restriction < 1.5 L/day

9. Tab. PCM 500 mg PO SOS

10. Tepid sponging

11. Abdominal girth measurement daily

Day 9 (22/10/22)

S

B/L pedal edema (Pitting) Grade 3 till thigh

O

Patient is conscious, coherent, cooperative

Temp-98.2 F

BP- 120/90 mmHg

PR- 78 bpm

RR- 16 cpm

CVS- S1,S2 +

RS- BAE+

CNS- HMF+

P/A- Soft, NT

SPO2- 94%

Abdominal girth- 91 cms

A

AKI with MODS

P

1.Inj. Meropenem 500 mg IV BD

2.Inj. Lasix 40 mg/IV/BD

3. Inj. Zofer 4 mg IV SOS

4. Inj. Rantac 50 mg IV OD

5. Tab. UDILIV 300 mg PO BD

6. Inj. Thiamine 1 amp in 100 ml NS IV OD

7. Salt restriction < 2g/dag

8. Fluid restriction < 1.5 L/day

9. Tab. PCM 500 mg PO SOS

10. Tepid sponging

11. Abdominal girth measurement daily

12. Syp. POTKLOR 10 ml /PO TID

AMC bed 5

Day 10 (23/10/22)

S

B/L pedal edema (Pitting) Grade 3 till thigh

O

Patient is conscious, coherent, cooperative

Temp-98.2 F

BP- 100/70 mmHg

PR- 75 bpm

RR- 16 cpm

CVS- S1,S2 +

RS- BAE+

CNS- HMF+

P/A- Soft, NT

SPO2- 97%

Abdominal girth- 88 cms

A

AKI with MODS

P

1. Inj. Meropenem 500 mg IV BD

2. Inj. Lasix 40 mg/IV/BD

3. Inj. Zofer 4 mg IV SOS

4. Inj. Thiamine 1 amp in 100 ml NS IV OD

5. Tab. Carvedilol 3.125 mg/ PO/OD

6. Tab. PCM 500 mg/ PO/ SOS

7. Syrup POTKLOR 15 ml in 1 glass of water/ PO/TID

8. Oint. Thrombophobe for E/A

9. Tepid sponging

10. Salt restriction < 2g/dag

11. Fluid restriction < 1.5 L/day

12. Abdominal girth measurement daily

Medical ward

26/10/22

S

B/L pedal edema (Pitting) - Resolved

O

Patient is conscious, coherent, cooperative

Temp-98.2 F

BP- 120/80 mmHg

PR- 78 bpm

RR- 17 cpm

CVS- S1,S2 +

RS- BAE+

CNS- HMF+

P/A- Soft, NT

SPO2- 97%

Abdominal girth- 88 cms

A

AKI with MODS

P

1. Tab. Rantac 150 mg PO/OD

2. Tab. PCM 500 mg/ PO/ SOS

3. Oint. Thrombophobe for E/A

4. Salt restriction < 2g/dag

5. Fluid restriction < 1.5 L/day