A 75 year old male with ? PreRenal AKI secondary to acute GE

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CBBLE UDHC SIMILAR CASES 

"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box"

A 75 year old male patient, Shepard by occupation, came with C/O generalized  weakness, constipation, decreased urine output and vomitings since 2-3 months.

HOPI:
Patient was apparently normal one and half year ago, then he developed B/L knee joint and hip joint pains gradually progressing to a state where he could not walk and stopped his routine activity. 

Since then he is doing his day to day regular activities by crawling. 

Since 2-3 months patient developed vomitings, which were non-projectile, non-bilious with dark coloured (?blood) contents, which was associated with decreased urine output and constipation. Patient used soap water enema 1-2 times/week to get rid of constipation since 2-3 months.


Past H/O:
 No history of similar complaints in the past.
No H/O DM,HTN,TB,CAD,CVD

Family H/O: 
No significant family history.

Personal H/O:
Appetite- Lost
Bowels- Constipation present 
Addictions- Smoking tobacco since 60 years

GENERAL EXAMINATION: 
O/E : Patient is C/C/C
Clubbing - present
Pallor - absent
Icterus  absent
Cyanosis - absent
Edema of feet - absent
Lymphadenopathy  - absent


VITALS:- 
 BP: 160/100mmhg
 PR: 108 bpm 
 RR: 20cpm 
 Spo2: 98%

SYSTEMIC EXAMINATION : 
CARDIOVASCULAR SYSTEM : S1 and S2 heard, no murmurs heard 
RESPIRATORY SYSTEM : BAE present
P/A : soft 
CNS: NAD



Investigations:


S. Urea- 73
S. Creat- 1.3

Chest x-ray
ECG
Diagnosis:
? PreRenal AKI secondary to acute GE

Treatment:
1.IVF NS RL 75ml/hr
2.Inj. PAN 40mg IV/ OD
3. Inj. Zofer 4mg/IV SOS
4. Inj. Optineuron 1amp in 100ml NS/IV/OD
5. Plenty of oral fluids 
6. Strict I/O charting 
7. Monitor vitals and inform SOS


Soap notes
26/2/22
S: Complains of vomitings decreased
     No fever 
O: 
O/E: 

Patient is conscious, coherent and cooperative. 
Clubbing present 
No pallor/icterus/cyanosis/generalized lymphadenopathy/pedal oedema 
Temp: afebrile
BP: 130/70 mmhg
PR: 82bpm
CVS: S1S2 +
RS: BAE +
P/A: soft and NT 

A: pre renal AKI secondary to ?Acute GE 

P: 
1.IVF NS RL 75ml/hr
2.Inj. PAN 40mg IV/ OD
3. Inj. Zofer 4mg/IV TID
4. Inj. Optineuron 1amp in 100ml NS/IV/OD
5. Plenty of oral fluids 
6. Strict I/O charting 
7. Monitor vitals and inform SOS

27/2/22
S: No vomitings 
     No fever 
O: 
O/E: 

Patient is conscious, coherent and cooperative. 
Clubbing present 
No pallor/icterus/cyanosis/generalized lymphadenopathy/pedal oedema 
Temp: afebrile
BP: 110/70 mmhg
PR: 82bpm
CVS: S1S2 +
RS: BAE +
P/A: soft and NT 

A: pre renal AKI secondary to ?Acute GE 

P: 
1.IVF NS RL 75ml/hr
2.Tab. PAN 40mg PO/ OD
3. Inj. Zofer 4mg/IV SOS
4. Inj. Optineuron 1amp in 100ml NS/IV/OD
5. Plenty of oral fluids 
6. Strict I/O charting 
7. Monitor vitals and inform SOS

28/2/22
S: Constipation present 
 No vomitings
 No fever 
   
O: 
O/E: 

Patient is conscious, coherent and cooperative. 
Clubbing present 
No pallor/icterus/cyanosis/generalized lymphadenopathy/pedal oedema 
Temp: afebrile
BP: 120/70 mmhg
PR: 78bpm
Urine output: 100ml (emptied at 7am)
CVS: S1S2 +
RS: BAE +
P/A: soft and NT 

A: pre renal AKI secondary to ?Acute GE 

P: 
1.IVF NS RL 75ml/hr
2.Inj. PAN 40mg IV/ OD
3. Inj. Zofer 4mg/IV SOS
4. Inj. Optineuron 1amp in 100ml NS/IV/OD
5. Plenty of oral fluids 
6. Strict I/O charting 
7. Monitor vitals and inform SOS




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