A 73 yr old female with LEFT HYDRO URETERONEPHROSIS POST RENAL AKI SECONDARY TO URETERIC OBSTRUCTION K/C/O HYPERTENSION SINCE 3 YEARS

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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

Case History and Clinical Findings: 
A 73 yr old Female patient came with
C/O BREATHLESSNESS ON EXERTION SINCE 4 DAYS 

HISTORY OF PRESENT ILLNESS:-
PATIENT WAS APPARENTLY ASYMPTOMATIC 4 DAYS BACK THEN DEVELOPED BRETHLESSNESS ON EXERTION INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE GRADE II NYHA RELIEVED WITH REST. ASSOCIATED WITH ORTHOPNEA AND PND, NO SYNCOPE ,PALPITATIONS PRESENT.
 NO H/O COUGH COLD FEVER EXCESSIVE SWEATING H/O PEDAL EDEMA PITTING IN TYPE EXTENDING UPTO KNEE
 NO H/O PAIN ABDOMEN BURNING MICTURITION
 H/O DECREASED URINE OUTPUT 
PAST HISTORY::-
K/C/O HTN SINCE 3 YEARS ON TAB TELMA 40MG N/K/C/O DM-II/CVA/CAD/THYROID/SEIZURE DISORDERS

 GENERAL EXAMINATION:
 PATIENT IS CONSCIOUS ,COHERENT , COPERATIVE TEMPERATURE- 98.6 F
PR 84 BPM RR 16CPM BP 110/70 MMHG 

SYSTEMATIC EXAMINATION:
 CVS S1S2 + NO MURMURS
 RS BAE+ 
CNS NFND
 P/A : SOFT AND NON TENDER.
 NO ORGANOMEGALY. 

*SURGERY REFFERAL WAS DONE I/V/O BURNING SENSATION DURING DEFECATION
 DIAGNOSIS- ACUTE FISSURE IN ANO 
ADVISED SYRUP CREMAFFIN 5ML/PO/HS
 OINT SMUTH FOR LA 
SITZ BATH WITH POVIDINE IODINE WITH LUKEWARM WATER 
TAB PAN 40MG PO/OD, 
HIGH FIBRE DIET REVIEW SOS

*OPHTALMOLOGY REFFERAL WAS DONE I/V/O RETINOPATHY CHANGES IMPRESSION - FUNDUS EXAMINATION OF BOTH EYES - GRADE III HYPERTENSIVE RETINOPATHY CHANGES NOTED IN LEFT EYE AND RIGHT EYE FUNDUS EXAMINATION COULDNOT BE ELICITED DUE TO PRESENCE OF PCO

 *GASTRO REFFERAL WAS DONE I/V/O BLACK COLOURED STOOLS AND PAIN ABDOMEN ADVISEDINJ PAN 4GM IV TID

* URO REFFERAL WAS DONE I/V/O LEFT HYDROURETERONEPHROSIS ON26/03/24 ADVISEDNCCT KUB AND REVIEW WITH SERUM CREATININE AND BLOOD UREA 

*REVIEW URO REFFERAL WAS DONE ON 29/03/24ADVISED- SYRUP ALKASTONE B6 15ML IN 100ML OF WATER TWICE DAILY 

INVESTIGATIONS::-

COMPLETE BLOOD PICTURE (CBP) 27-03-2024 11:13:AM 
HAEMOGLOBIN 7.5 gm/dl 
TOTAL COUNT 8900 cells/cumm  
NEUTROPHILS 80 % 80-40 %
LYMPHOCYTES 11 % 40-20 %
EOSINOPHILS 00 % 6-1 %
MONOCYTES 9 % 10-2 %
BASOPHILS 00 % 2-0 %
PLATELET COUNT 1.20
SMEAR Normocytic normochromic blood picture with thrombocytopenia 

COMPLETE BLOOD PICTURE (CBP) 30-03-2024 11:13:AM 
HAEMOGLOBIN 14.6 gm/dl 17.0-13.0 gm/dl
TOTAL COUNT 5400 cells/cumm 10000-4000 cells/cumm
NEUTROPHILS 70 % 80-40 %
LYMPHOCYTES 20 % 40-20 %
EOSINOPHILS 00 % 6-1 %
MONOCYTES 10 % 10-2 %
BASOPHILS 00 % 2-0 %
PLATELET COUNT 1.0
SMEAR Normocytic normochromic blood picture with thrombocytopenia 

COMPLETE BLOOD PICTURE (CBP) 29-03-2024 11:13:AM
HAEMOGLOBIN 9.7 gm/dl 17.0-13.0 gm/dl
TOTAL COUNT 12500 cells/cumm 10000-4000 cells/cumm
NEUTROPHILS 80 % 80-40 %
LYMPHOCYTES 10 % 40-20 %
EOSINOPHILS 00 % 6-1 %
MONOCYTES 08 % 10-2 %
BASOPHILS 00 % 2-0 %
PLATELET COUNT 1.20
SMEAR  ::+Normocytic normochromic blood picture with thrombocytopenia and leukocytosis
 RFT -30-03-2024 
BLOOD UREA- 57MG/DL 
URIC ACID 6.2 MMOL/L 
SERUM CREATININE 2,2MG/DL
SERUM ELECTROLYTES (Na, K, C l)
SODIUM 133 mmol/L 145136 mmol/L
POTASSIUM 3.4 mmol/L 5.1-3.5 mmol/L
CHLORIDE 103 mmol/L 98-107 mmol/L 

RFT -29-03-2024
 BLOOD UREA- 60MG/DL 
URIC ACID 7.3 MMOL/L 
SERUM CREATININE 1.9MG/DL
SERUM ELECTROLYTES (Na, K, C l)
SODIUM 132 mmol/L 145136 mmol/L
POTASSIUM 3.4 mmol/L 5.1-3.5 mmol/L
CHLORIDE 97 mmol/L 98-107 mmol/L 

LIVER FUNCTION TEST (LFT) 29-03-2024
 Total Bilurubin 0.97 mg/dl
Direct Bilurubin 0.20 mg/dl 0.20.0 mg/dlS
GOT(AST) 14 IU/L 35-0 IU/L
SGPT(ALT) 12 IU/L 45-0 IU/L
ALKALINE PHOSPHATASE 142 IU/L 119-56 IU/LTOTAL PROTEINS 5.1 gm/dl 8.3-6.4 gm/dl
ALBUMIN 2.5 gm/dl 4.6-3.2 gm/dl
A/G RATIO 0.98 
STOOL FOR OCCULT BLOOD - NEGATIVE
 
COMPLETE URINE EXAMINATION (CUE) 30-03-2024
COLOUR -Pale yellow
APPEARANCE Clear
REACTION Acidic
SP.GRAVITY 1.010
ALBUMIN trace
SUGAR Nil
BILE SALTS Nil
BILE PIGMENTS Nil
PUS CELLS 3-4
EPITHELIAL CELLS 2-3
RED BLOOD CELLS Nil
CRYSTALS Nil
CASTS Nil
AMORPHOUS DEPOSITS AbsentOTHERS Nil

 CT SCAN - ABDOMEN(PLAIN) DONE ON 27/03/24: IMPRESSION ::- 
LEFT URETERIC CALCULUS LEFT MODERATE HYDROURETERONEPHROSIS CHOLELITHIASIS
 
USG DONE ON 25/3/24
IMPRESSION::-
CHOLELITHIASIS LEFT KIDNEY SHOWS RAISED ECHOGENECITY WITH FOCAL CALIECTASIS AND HYDROURETERO NEPHROSIS 
2D ECHO DONE ON 25/03/24
NO RWMA 
MILD TR WTH PAH TRIVIAL AR
 NO MR SCLEROTIC AV
 NO AS/MS 
IAS-INTACT 
EF-65% 
RVSP 28+10=38MMHG 
GOOD LV SYSTOLIC FUNCTION
 GRADE I DIASTOLIC DYSFUNCTION MILD DE + IVC SIZE 0.5CMS COLLAPSING
DIAGNOSIS::-
LEFT HYDRO URETERONEPHROSIS POST RENAL AKI SECONDARY TO URETERIC OBSTRUCTION
 K/C/O HYPERTENSION SINCE 3 YEARS
 1PINT PRBC TRANSFUSION DONE ON 27/03/24 

Treatment Given:
- 1PINT PRBC TRANSFUSION DONE ON 27/03/24
 -IV FLUIDS 1 PINT NS @ U.O +30ML/HR
- INJ AUGMENTIN 625MG IV/BD
- INJ NEOMOL 1GM IV/SOS (TEMP>101F) 
- INJ ONDEM 4MG IV/BD
- INJ LASIX 40MG IV/BD 
-NEB WITH BUDECORT-12TH HRLY PLUS IPRAVENT - 6TH HRLY 
- TAB CLOPITAB AV 75/20 PO/HS 
- INJ OPTINEURON 1AMP IN 100ML NS IV OD
- INJ IRON SUCROSE 200MG IN 100ML NS IV ON   - - -ALTERNATE DAYS ORS SACHET IN 1 LITRE OF WATER TAB LARIAGO DS 1KIT/PO
- PROTEIN POWDER 1 TEASPOON IN 1 GLASS OF MILK/BD
-INJ .DOXYCYCLINE 100MG IV/BD 
 -INJ .CLINDAMYCIN 600MG IV/OD
- INJ .CEFTRIAXONE 1 MG IV/BD              
-SYPRUP ALKASTONE B6 15ML IN GLASS WATER TWICE DAILY
- TAB TAMSULOSIN 0.4MG PO/HS     -   TAB.DOXYCYCLINE 100MG PO/BD 
-TAB CLINDAMYCIN 600MG PO/BD 
-TAB GUDCEF CV 200MG PO/BD
- TAB P650MG PO/BD 
-TAB ZOFER PO/BD 
-TAB MVT PO/OD 
-TAB LARIAGO DS 3 EGG WHITES PER DAY 
-TAB LASIX 20MG PO/BD MONITOR VITALS.
 
Advice at Discharge:
 TAB. CLOPITAB AV 75/20 PO/HS X 10DAYS 
TAB .TAMSULOSIN 0.4MG PO/HS X 10DAYS TAB.DOXYCYCLINE 100MG PO/BD X 10DAYS
 TAB .CLINDAMYCIN 600MG PO/BD X 10DAYS 
TAB .LASIX 20MG PO/BD X 10DAYS 
TAB .PAN 40MG PO/OD X 10DAYS 
TAB .MVT PO/OD X 10DAYS
Follow up: Limitation in physical activity

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