60 Y/O FEMALE WITH REDUCED URINE OUTPUT AND LOOSE STOOLS

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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.


A 60 Y/O patient came to the casualty with complaints of

  1. Decreased urine output since one day
  2. Loose stools 7-8 episodes since 1 day

HOPI

Pt was apparently asymptomatic till the previous morning, then she developed loose stools (7-8 episodes till today morning), which are watery in consistency, non blood tinged,non mucopurulent associated with abdominal pain and fever ( low grade not associated with chills and rigor).Now abdominal pain and loose stools subsided. 

Patient also has c/o decreased urine output (anuria) since today morning which is previously not associated with dribbling of urine,hesitancy, urgency, burning micturition ,

H/o toddy consumption 2 days ago 

Past History:-

  • K/c/o DM-2 since two years ( on Tab metformin 500mg po/od)
  • K/c/o HTN since 2 years ( on tab amlodipine 5mg+tab lisinopril 5mg)
  • K/c/o hypothyroidism since 2 years ( on tab thyronorm 50 mcg)
  • N/k/c/o cad,cva,epilepsy, tb,asthma
  • Diagnosed with osteoarthritis 10 years back. Uses medication intermittently. Uses Ayurvedic drugs. 

Personal history:-

  • Diet - vegetarian 
  • Appetite- adequate 
  • Sleep-adequate 
  • Bowel and bladder movements- reduced micturition since today morning ,bowel movements regular 
  • Addictions- occasional toddy drinker 


Daily Routine:

Patient wakes up in the morning around 6 am freshens up and does her daily chores. Her grandchildren live with her during the school year so she gets them ready and sends them to school  She has breakfast at around 10 am usually consisting of chapati or upma. She then relaxes for some time and waits for her grandchildren to come back at 1 and has lunch with them. Afterwards she passes time by taking a nap and chatting with her neighbours. She then has dinner at 7 and sleeps by 8 pm. The patient's attender says she has been more irregular with meals since the past 2 years after her husband passed away. 


General examination:-

  • Patient is conscious, coherent, cooperative well oriented to time, place and person 
  • Pallor, icterus,cyanosis ,clubbing, lymphadenopathy,bilateral pedal edema absent 

Vitals :-

  • PR-98 bpm
  • BP-100/60 mmhg
  • RR-18 cpm
  • Spo2- 99% @ RA
  • GRBS-120 mg% 








Systemic examination:-

Per Abdomen 

  • Inspection: Round, large with no distention, Umbilicus: Inverted, No visible pulsation,peristalsis, dilated veins and localized swellings.
  • Palpation: Soft, non tender, No signs of organomegally 
  • Percussion:  No fluid thrill, shifting dullness absent 
  • Auscultation:  Bowel sounds heard


CVS: 

Inspection: 

  • There are no chest wall abnormalities 
  • The position of the trachea is central. 
  • Apical impulse is not observed. 
  • There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses. 

Palpation: 

  • Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line 
  • Position of trachea was central 

Auscultation: 

  • S1 and S2 were heard 
  • There were no added sounds / murmurs. 


RESPIRATORY SYSTEM: 

  • Bilateral air entry is present 
  • Normal vesicular breath sounds are heard. 


CNS: 

HIGHER MENTAL FUNCTIONS- 

  • Normal
  • Memory intact 

CRANIAL NERVES : Normal 

SENSORY EXAMINATION: Normal sensations felt in all dermatomes 

MOTOR EXAMINATION 

  • Normal time in all limbs
  • Power 4/5 bilateral UL and LL
  • Gait normal

REFLEXES

  • Normal, brisk reflexes elicited- biceps, triceps,
  • Knee and ankle reflexes not able to elicit due to b/l osteoarthritis 

CEREBELLAR FUNCTION 

  • Normal function 
  • No meningeal signs were elicited


Provisional diagnosis:-

ACUTE KIDNEY INJURY (RENAL) ON ?POST RENAL (STRICTURE URETHRA) CHRONIC KIDNEY DISEASE ( STAGE 5 ESRD) WITH ?SEPTIC SHOCK WITH OSTEOARTHRITIS B/ L KNEES WITH HTN, DM, HYPOTHYROIDISM


Treatment:-

1.Salt restriction < 2g / day

2.Fluid restriction < 2l/ day

3.IVF ns,rl,@ u.o +30 ml/hr

4.Inj noradrenaline 1amp + 46 ml ns @ 5ml/ hr( 18mg/hr) increase/ decrease to maintain MAP >65 mmhg

5.inj Lasix 40 mg/iv/od ( if sbp >100 mmhg after informing icu/ nephritis pg )

6. Inj sodium bicarbonate 25meq + 100 ml ns slowly over 30 min 

7.tab thyronorm 50 mcg/po/od/bbf 

8.tab nodosis 500mg/po/ bd

9.tab orofer- xt /po/od (1-×-×)

10. Tab shelcal / po/ od (×-1-×)

11. Monitor vitals 

12. Strict io charting 

13. Inj neomol 1g/iv/ if temp >101 f

15. Tab dolo 650 MG/ po/sos

16. Tepid sponging 

17. Inj Piptaz 4.5 gm iv/ Stat ( day 1)

                           F/b 

         Inj piptaz 2.25 gm iv/ tid


INVESTIGATIONS

  • Hb 8.2 gm/dl
  • TLC 7200
  • N/L/E/M 77/18/1/4
  • PCV 25.6
  • PLT 2.23
  • SMEAR Microcytic hypochromic


RFT

  • Urea 121
  • Creatinine 7.5
  • Uric acid 10.4
  • Ca 8.8
  • P 6.0
  • Na 136
  • K 4.0
  • Cl 102
ABG

  • ph 7.27
  • pCO2 18.8
  • PO2 85.1
  • HCO3 8.5
  • Blood Lactate 16

Serum iron 34







BP Charting

17/5/23

  • 8 pm 80/40
  • 9 pm 80/60  NA INFUSION started @ 5ml/hour
  • 11pm 70/40 NA infusion @ 5ml/hour

18/5/23

  • 12am 100/60 NA infusion @ 5ml/hour
  • 2am 80/40 NA infusion @ 4ml/hour
  • 3am 130/70 NA infusion @ 4ml/hour
  • 4am 110/60 NA INFUSION @3ml/hour
  • 5am 110/60 NA INFUSION @3ml/hour
  • 8am 100/60NA INFUSION @3ml/hour
  • 10am 110/70NA INFUSION @3ml/hour
  • 11am 110/70 NA INFUSION @3ml/hour
  • 6 pm 120/80 @3ml/hour
  • 7 pm 130/70 @5ml/hour
  • 8 pm 120/70 @5ml/hour
  • 10 pm 100/50 @5ml/hour

19/5/23

  • 12 am 100/70 @5ml/hour
  • 2 am 100/70 @5ml/hour
  • 4 am 100/70 @5ml/hour
  • 6 am 100/60  @4ml/hour
  • 8 am 120/70 @4ml/hour
  • 10 am 100/60 @4ml/hour
  • 12 pm 120/70 @3 ml/hour
  • 2 pm 110/70 @3 ml/hour


SOAP NOTES

18/5/23

S

  • stools not passed
  • no fever spikes
  • unable to lift her rt hand (1st 30° abduction) since yesterday night after rt IJV catheter placement 

O 

  • PT c/c/c 
  • BP 100/60
  • PR 100
  • Temp 100. 2
  • RR 44
  • SpO2 96
  • CVS S1S2 heard
  • R/S BAE +  NVBS
  • P/A SOFT, non tender
  • CNS - NFND

A

  • AKI (renal) on ? post renal(?stricture urethra)
  • CKD(stage 5 ESRD)
  • with ? septic shock
  • with osteoarthritis b/l knees
  • HTN +   DM+    HYPOTHYROIDISM 

P

1.Salt restriction < 2g / day

2.Fluid restriction < 2l/ day

3.IVF ns,rl,@ u.o +30 ml/hr

4.Inj noradrenaline 1amp + 46 ml ns @ 5ml/ hr( 18mg/hr) increase/ decrease to maintain MAP >65 mmhg

5.inj Lasix 40 mg/iv/od ( if sbp >100 mmhg after informing icu/ nephritis pg )

6. Inj sodium bicarbonate 25meq + 100 ml ns slowly over 30 min 

7.tab thyronorm 50 mcg/po/od/bbf 

8.tab nodosis 500mg/po/ bd

9.tab orofer- xt /po/od (1-×-×)

10. Tab shelcal / po/ od (×-1-×)

11. Monitor vitals 

12. Strict io charting 

13. Inj neomol 1g/iv/ if temp >101 f

15. Tab dolo 650 MG/ po/sos

16. Tepid sponging 

17. Inj Piptaz 4.5 gm iv/ Stat ( day 1)

                           F/b 

       Inj piptaz 2.25 gm iv/ tid

18. Plan for hemodialysis

Neurosurgery referral 










19/5/23

S

  • stools not passed
  • unable to lift her rt hand (1st 30° abduction) since yesterday night after the insertion of rt IJV catheter placement 

O

  • PT c/c/c 
  • BP 120/70
  • PR 89
  • Temp 98
  • RR 21
  • SpO2 98
  • GRBS 138 mg/dl
  • I/O 2100/1000 ml
  • CVS S1S2 heard
  • R/S BAE + NVBS
  • P/A SOFT, non tender
  • CNS - NFND


A

  • AKI (renal) on ? post renal(?stricture urethra)
  • ?2° to ACUTE GASTROENTERITIS ON 
  • CKD(stage 5 ESRD)
  • with ? septic shock
  • with osteoarthritis b/l knees
  • HTN + DM+ HYPOTHYROIDISM 


P

1.Salt restriction < 2g / day

2.Fluid restriction < 2l/ day

3.IVF ns,rl,@ u.o +30 ml/hr

4.Inj noradrenaline 1amp + 46 ml ns @ 5ml/ hr( 18mg/hr) increase/ decrease to maintain MAP >65 mmhg

5.inj Lasix 40 mg/iv/od ( if sbp >100 mmhg after informing icu/ nephritis pg )

6.tab thyronorm 50 mcg/po/od/bbf 

7.tab nodosis 500mg/po/ bd

8.tab orofer- xt /po/od (1-×-×)

9. Tab shelcal / po/ od (×-1-×)

10. Inj Piptaz 2.25 gm IV/TID(1-1-1)

11. Inj Neomol 1 gm IV/SOS(IF temp >101F)

12. Tab DOLO 650 mg PO/SOS

13. Monitor vitals 

14. Strict io charting

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