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A 15 years old male with acute kidney injury

                                                             E-LOG  OF  CASE 

 Greetings to all my readers.

 I am Pranathi , a second year MBBS student. This is an e-log documenting the patients that I witness during my Clinical Postings to enforce a greater patient centered learning.

Date - 15th November 2021

      Chief Complaints :  

            A 15 yr old male ,studying 9th class came to the casualty with Shortness Of Breath since 4 days,  No H/O fever, vomitings.

      History of presenting illness:   

Pt was apparently asymptomatic 1 month back ,pt complains of vomitings 2 - 3 episodes daily associated with food particles not associated with blood ,for around 1 month 

H/O fever 1 month back associated with chills ,relieved with medication by 2 days . The patient found to have increased blood Creatinine levels,  went to Hyderabad  and within 1 day blood urea levels found to be raised very high . And  he was started  on dialysis .5 sessions of Hemodialysis done and  pt C/O SOB since 4 days evening aggravating on supine position  Complains of chest pain ,dragging type only during episode of sob . No C/O decreased urine output ,pedal edema ,facial puffiness

   Past History :  

          Hypertensive since 1 month and is on Tab.AMLONG 5 mg

         History of 3 transfusions 1 month back

         He is not a K/C/O Hypertension ,Diabetes Mellitus ,Bronchial Asthma ,Coronary Artery             Diseases or Epilepsy.

 Family History :

  • No H/O renal problems in their whole family. 
  • No relevant family history 

       Personal History:   

  •  Diet - mixed 
  •  Appetite - normal 
  • Sleep - adequate
  •  Bowel movements : regular
  •  Bladder movements : regular 
  • No history of alcohol consumption or smoking history 

      General Examination:

         Patient is conscious , coherent and co-operative 

    •   Pallor: - Not seen 
    •   Icterus: - Not seen
    •   Cyanosis: - Not seen
    •   Clubbing: - Not seen
    •   Koilonychia: - Not seen
    •   Lymphadenopathy: - Not seen
    •   Edema: - Not seen  








                                                        

        O/E: 

             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: S1,S2 heard no murmurs, No thrills.
    • CNS: normal 
    • RS : Position of trachea- central .                                                                                                                Bilateral Air Entry - present                                                                                                                Bilateral crepitation heard at IAA and ISA.                                                                                        No wheeze . 
    • Per Abdomen :                                                                                          Soft ,non tender Bowel sounds + 
    • CNS: NAD
                Investigations :
                                             COMPLETE URINE EXAMINATION



    CHEST  X-RAY 




    SERUM CREATININE

    2D - ECHO



                                                               RENAL  FUNCTION  TEST


                                                                         BLOOD  UREA
                           
                                     

                                                              LIVER  FUNCTION   TEST


    COMPLETE BLOOD PICTURE


                                                                    SERUM CREATININE
                                    
                                                                                                                                                                    USG finding : Bilateral grade 1 rpd changes :



    PROVISIONAL DIAGNOSIS : Acute Kidney Injury (AKI) secondary to ? PSGN ? IgA nephropathy                                                         ? Minimal change disease ??

    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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