15 YEARS OLD MALE PATIENT WITH ACUTE KIDNEY INJURY


15 YEARS OLD MALE PATIENT WITH ACUTE KIDNEY INJURY 


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Name : K. Supriya (9th semester)

Roll number : 53 

I have 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 diagnosis and treatment plan

Presenting complaints :

Shortness of breath since 4hrs ,Grade ll -III according to NYHA classification ,associated with orthopnea 

Chest pain since 4hrs 

This 15 year old male patient ,who is 9th standard student from gurukul school ,Nalgonda , he is a boarding student ,who is staying in hostel from past 5 years ,but due to Corona ,he is at home since 2years.

      As he is staying at home since 2years, this history is according to his grand mother .

          He is active person and interested in  outdoor games,he usually wakes up at around 8am and have breakfast (idly/dosa /wada etc)at 9am ,and play different games with his friends and have lunch(rice &curry) at around 12:30pm ,have some tea in the evng and have dinner(chapathi/ rice) at night 8pm.His diet is mixed but takes very little amount of water intake (like 2-3 glasses in a day).

     He is a term child,breast fed upto 1year .

     He is a child of parents (third degree consanguineous marriage).no delayed milestones and no physical abnormalities and have good IQ.

 HOPI :

           Patient  was  apparently assymptomatic 1 month ago , then he had vomitings (non bilious with food particles,no blood )at night almost daily upto one week for which he was treated at local hospital and diagnosed with renal problem on evidence from investigation report shown elevated serum urea and creatinine and USG abdomen reports shown bilateral kidney size of 8.1cm with loss of CMD& increased echotexture with  grade l RPD changes then he is referred to Hyderabad ,where he undergone  5 series of hemodialysis then came to nalgonda ,again 4 series of hemodialysis done ,actually today he has dialysis session but all of a sudden he developed  SOB at night 

           Shortness of breath is  aggravated on supine position ( orthopnea) .and no PND 

            Chest pain associated with SOB ,which is of dragging type .

            No H/O fever,chills & rigor since one month

            No H/O decreased urine output , burning micturation ,pedal edema and facial puffiness .

            No H/O palpitations and syncopal attacks .

           Previous reports : 















Past History: 

Not a K/C/O diabetes ,Asthma ,TB 

Hypertension was diagnosed on diagnosis of renal problem  and patient is on Amlodipine 5mg since then .

H/O seizures at age of 2yrs .( Only once till now  ),for which he was treated .

Family History :

No H/O renal problems in their whole family .

Personal History:

Appetite -normal

Diet -mixed 

Bowel and bladder movements - regular 

Sleep - adequate 

No allergies and addictions 

General Examination:

Patient is conscious, coherent , cooperative

Pallor -present 

Icterus -absent 

Clubbing-absent 

Cyanosis -absent 

Lymphadenopathy-absent 

Edema -absent 

Vitals : 

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

Inspection :

Shape of the chest : elliptical (transverse diameter is more than AP diameter )

Symmetry: bilaterally symmetrical

Position of trachea : central 

there is no precordial bulge ,

         ,no scars and sinuses ,no engorged veins 

Palpation :

All inspectory findings are confirmed 

Position of trachea is central 

Apex beat -at left  5th intercostal space (1cm medial to mid clavicular line) 

No thrills .

Auscultation :

S1S2 HEARD 

No murmurs 

RS :

Bilateral Air Entry - present 

Bilateral crepitations heard at IAA and ISA.              

No wheeze .

PA: 

Soft ,non tender 

Bowel sounds + 

CNS:

NAD 


Investigations :












Chest x ray :

Tachypnoea :



ECG report :
        


 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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