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Here is a case I've seen:
A 75 year old female who's a farmer by occupation, a resident of a village nearby, presented to the hospital 5 days back with chief complaints of decreased urine output a/w burning micturition since 15 days and SOB since 7 days.
HOPI
The patient was apparently asymptomatic 15 days back,then she noticed decrease in her urine output a/w burning micturition.
10 days back, she had epigastric pain a/w Vomitings(2-3 episodes/day, nonbilious,not bloodstained) and loose stools (3-4 episodes/day,non blood stained) for 2 days.Then she developed severe SOB with orthopnea since 7 days, progressive in nature,not a/w PND. no h/o fever,cough.
She developed mild abdominal distension since 2days with diffuse tenderness, more in RUQ,not passing stools from 6 days.
H/o altered sensorium (hypoactive and drowsy) on the day of admission.
No H/o syncopal attacks,joint pains
The patient was started on Haemodialysis on 22/7/20.
She has undergone dialysis for 3 times now:
1st on 22/7/20
2nd on 23/7/20
3rd on 26/7/20
On 26/7/20,she came back to ICU after dialysis at 10:30 am. At around 11:30am ,she complained of severe SOB and left sided chestpain around 12pm.
IV Labetalol 15mg bolus was given stat. She was also hypoglycemic (GRBS-50mg/dl) for which 25-D 100ml bolus was given. ECG showed Tachyarrythmias with Anteroseptal MI. NIV with BiPAP was given,after which her O2 saturations raised gradually from 65% -70%-85%-95%. Pt. recovered in few hours.
4th dialysis on 28/7/20
5th on 29/7/20
In the mrng,she was tachypneic(RR 45) with severe SOB,tachycardia....chest x-ray showed pulmonary edema.Ipravent nebulisation and BiPAP were given along with 80 mg lasix. pt. was made to lie down in prone position for alveolar recruitment. Saturations were fluctuating..BP 150/100mmhg. Sent for dialysis after an hour.she returned to ICU at 6:30pm. BP 140/100mmhg,RR 31cpm..her symptoms subsided post dialysis around 7pm.
Past history
Pt. Underwent 'Incision and Drainage' at our hospital for gluteal abscess that spontaneously developed 6 yrs back,was treated with antibiotics and NSAIDS.
K/c/o HTN since 5years on Tab. Telma 40 mg;
DM 2 since 5yrs on Tab. Glimy M1
K/c/o CKD since 5yrs on conservative management. The lady developed fever with pedal edema and facial puffiness 5yrs back which subsided on using medication prescribed by a local physician.Lab Inv. revealed mildly elevated creatinine levels & usg showed grade 1 RPD changes.she was incidentally found to be hypertensive & type 2 diabetic and was put on medication for the past 5 years. She was asymptomatic during this period of 5years. She stopped working in fields since then.
No H/O TB, asthma, epilepsy,jaundice,CHD
NO H/O Blood transfusion
Personal history
Diet: mixed
Sleep: inadequate
Bladder movements: decreased urine output
Bowel: not passing stools regularly
Addictions: none
Menstrual hx: insignificant
Marital hx: married at the age of 15 yrs,has 7 children (2 sons and 5 daughters)
Lives with husband,younger son, youngest daughter & their kids.
Family history
No similar history in the family
Drug history
Not allergic to any known drug
General Examination:
Pt. is conscious, coherent and cooperative
Moderately built and moderately nourished.
Pallor +
No signs of icterus, Cyanosis,clubbing,koilonychia,generalised lymphadenopathy, pedal edema
Vitals:
Temp- afebrile
BP - 130/80 mmhg,right arm,supine position
PR- 86bpm,regular rate& rhythm,normal in volume
RR- 22 cpm
SpO2 - 88% on 12 Lt of O2
GRBS- 154 mg/dl
Systemic Examination:
Per abdomen
Inspection:
Shape- obese,distended
Umbilicus- central
All quadrants are moving equally with respiration
No scars,sinuses,engorged veins
Hernial orifices- free
Multiple hyperpigmented cutaneous lesions seen on left side of abdomen,right inguinal region,neck and both legs.
Palpation:
No local rise of Temperature
Diffuse tenderness in all quadrants (>in RUQ)
Liver and spleen- not palpable
Percussion:
Tympanic note
Auscultation: bowel sounds are heard
Respiratory system
Inspection:
Chest shape - normal
Bilaterally symmetrical movements with respiration
Trachea- central
Grade 4 SOB ,Orthopnea present
Burn scar- on left breast, 1st degree burn,2yrs back due to hot water
Palpation: no local rise of temperature,no tenderness,equal movements with respiration,trachea is central
Percussion: resonant note
Auscultation: BLAE present,
B/L coarse end-inspiratory crepts in all areas
Cardiovascular system
S1 S2 heard,no murmurs
CNS
Patient is conscious, coherent, cooperative;
well oriented to time, place and person.
Hypoactive and drowsy on the day of admission.
Speech - normal
No signs of meningeal irritation
Higher mental functions- normal
cranial nerves- intact
motor system- normal
sensory system - normal
Reflexes :
Right Left
Biceps +2 +2
Triceps +2 +2
Supinator +2 +2
Knee +2 +2
Ankle +2 +2
Plantar Flexor Flexor
Based on the clinical findings, the following investigations were advised-
CBP
PT,INR,aPTT
CUE
RFT
ABG
Serology
USG Abdomen
ECG
Chest X-ray
CBP
Day 1
Day 3
CUE
RFT
Before admission
Day 1
Day 2
ABG
Day 1
PT INR
aPTT
Blood grouping
Serology
ECG
Day 1
Day 4
Day 5
Day 6
Day 7 7:00am
Day 8
Day 9
Chest x-ray
Day 1
Day 2
Day 4
Day 8
Diagnosis:
Pre-renal Acute Kidney Injury 2° to Gastroenteritis (resolved) on CKD-5 started on Haemodialysis
With Anteroseptal MI
K/C/O DM type 2, HTN
Treatment:
1. Head end elevation
2. INJ.PIPTAZ 2.25gm/IV/TID
3. INJ.METROGYL 500mg/IV/TID
4. INJ.PANTOP 40mg/IV/BD
5. T. ECOSPIRIN 75mg
6. T.ATORVAS 40mg H/S
7. INJ.LASIX 40mg/IV/BD
8. INJ.ZOFER 4 mg/IV/SOS
9.GRBS 6th hourly
10. Oxygenation to maintain at SpO2>90%
11. Intermittent BiPAP every 2hours
12. Maintainance Haemodialysis
Excellent blog.
ReplyDeleteWhat caused the Gastroenteritis? Or was it secondary to Uremia ?
What is the cause of her CKD ?
What was the rationale to pick Piptaz in this patient - knowing that it is notorious for its nephrotoxicity ?