24 yr old male with chronic kidney disease with hydroureteronephrosis

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A 24 year old male who is a labourer , came with chief complaints of 

Decreased urine output since 10 days

Shortness of breath since 10 days 

Pedal edema since 10 days 

Fever since 10 days  

History of presenting illness 

The patient was apparently asymptomatic 3  years back. Then he developed decreased urine output for which he went to local hospital and scan was done which revealed hydronephrosis .10 days back he had a trauma to the left little finger and dorsum of right foot for which he went to local hospital and dressing was done .10 days back he developed shortness  of breath which was insidious in onset and gradually progressive (grade 4 ) aggravated on walking relieved on medication .

Pedal edema since 10 days which was extending till ankle 

Fever since 10 days which was continous , not associated with chills and rigour  

I/v/o increased serum creatinine dailysis was initiated yesterday

Past history :

 Not a K/c/o  DM , HTN , asthma , epilepsy , BA , TB ,CAD

No past surgical history 

No previous blood transfusions

When the patient was 3 years he had a distended abdomen and according to attender a Foley's was inserted and the complaint resolved 

Personal history  :

The patient was delivered by normal vaginal delivery , has delayed milestones , stopped school at the age of 6-8 yrs  , stayed at home and helps his family members in some chores but can't lift heavy weights . patient can't eat spicy foods he only eat curd rice and butter milk 

He cant communicate that much , he can't able to go to hair cut on his own .

On examination 

Patient is Consious , coherent and co operative 

Pallor +

Ictrerus -

Cyanosis -

Clubbing -

Lymphadenopathy -

Edema +

Afebrile

Bp:130/80 mm hg 

PR ; 88bpm regular

Cvs : s1 s2 +

Rs : BAE +

P/A: soft , non tender 

Provisional diagnosis:

Chronic kidney disease with hydroureteronephrosis

Investigations 

On 9/03/22

RFT:

Blood urea: 175 mg/dl

Serum creatinine : 9.3 mg/dl

Sodium : 144 meq/l

Potassium :3.6 meq/l

Chloride:106 meq/ l

ABG:

pH : 7.3mmhg

pCO2 : 7.8mm hg

pO2 : 123 mmhg

Sr. Hco3:

Past reports

Treatment :

Day 0

1.Inj piptaz 4.5 gm IV STAT F/B inj . Piptaz 2.25 gm IV / QID 

2.inj clindamycin 600 mg /IV / tid

3.inj pan 40 mg IV /od

4.Tab nodosis 500 mg po/bd 

5.Tab shellac 550 mg  po / od

6.IVF NS and RL @ 100 ml / hr 

7.Inj lasix 40 mg IV / bd if bp is more than 110 mm of hg 

8.Tab alpha  - D3

11/03/2022

Soap notes 

SUBJECTIVE

Decreased shortness of breath compared to yesterday

OBJECTIVE

Pt is c/c/c

Pallor +

Malnutrition +

Dehydration +

No cyanosis, Icterus,Lymphadenopathy 

Temp: afebrile

BP: 120/70 mm hg

PR: 86 bpm

CVS: s1, s2 heard

RS: BAE+

P/A: soft , non tender

ASSESSMENT-

Chronic kidney disease secondary to  hydroureteronephrosis

PLAN OF TREATMENT-

Day 2

1.IV fluids (NS)  30 ml/ hr

2.Inj piptaz 2.25 gm

3.Inj clindamycin 300 mg  Iv / tid

4.Inj pan 40 mg iv od

5.Inj lasix 40 mg  iv bd

6.Tab nodosis  500 mg bd

7.Tab shellac 500 mg od

8.Cap bio D3 0.25 mg 

9.Monitor vitals .

12/ 02/2022

On examination

Patient was conscious coherent cooperative

PR 91

RR 22

BP 150/90

Temp afebrile

CVS S1 S2 heard

RS BAE +

P/A : soft and non tender

Diagnosis : 

Acute kidney injury 2° to abscess in right leg or CKD with neurogenic bladder 

T/t

1. IVF NS 30 ml / hr

2.INJ PIPTAZ 2.25 gm IV QTD

3. INJ CLINDAMYCIN 300mg IV TID

4. INJ PAN 40 mgIV SOS

5. INK LASIX 40 mg IV BD

6. TAB NODOSIS 500mg BD

7. Tab SHELCAL 50Omg OD

8 . cap , B/O D3 0.25 MCG OD

9 . moniter vitals 

10. Tab fluconazole 150 mg BD

11. Syp POTKLOR 10ml PO TID 

      ( In glass of water)

12. Sporolac - DS

13 /03 /2022

On examination

Patient was conscious coherent cooperative

PR 84

RR 20

BP 140/70

SpO2 98%

Temp afebrile

CVS S1 S2 heard

RS BAE +

P/A : soft and non tender

Diagnosis

Acute kidney injury 2° to abscess in right leg or CKD with neurogenic bladder 

Treatment

. IVF NS 30 ml / hr

2.INJ PIPTAZ 2.25 gm IV QTD

3. INJ CLINDAMYCIN 300mg IV TID

4. INJ PAN 40 mgIV SOS

5. INK LASIX 40 mg IV BD

6. TAB NODOSIS 500mg BD

7. Tab SHELCAL 50Omg OD

8 . cap , B/O D3 0.25 MCG OD

9 . moniter vitals 

10. Tab fluconazole 150 mg BD

11. Syp POTKLOR 10ml PO TID 

      ( In glass of water)

12. INI ZOFER 4mg IV TID

14/03/2022

On examination

Patient was conscious coherent cooperative

PR :90

RR :22

BP : 

Temp 10@°F

CVS S1 S2 heard

RS BAE +

P/A : soft and non tender

Diagnosis

Acute kidney injury 2° to abscess in right leg or CKD with neurogenic bladder 

Treatment

. IVF NS 30 ml / hr

2.INJ PIPTAZ 2.25 gm IV QTD

3. INJ CLINDAMYCIN 300mg IV TID

4. INJ PAN 40 mgIV SOS

5. INK LASIX 40 mg IV BD

6. TAB NODOSIS 500mg BD

7. Tab SHELCAL 50Omg OD

8 . cap , B/O D3 0.25 MCG OD

9 . moniter vitals 

10. Syp POTKLOR 10ml PO TID 

      ( In glass of water)

11.INI ZOFER 4mg IV TID