37 Male with post renal AKI
A 38yrs old male patient presented with
CHIEF COMPLIANTS of loss of appetite since 6 months decreased sleep since 6 months, easy fatiguability from 4 months loin pain since 3 months and SOB from past 20days
HOPI
Patient was apparently asymptomatic 6months back then he had loss of appetite and decresed sleep(used to sleep nearly 8hours per day before).Then he had sob(grade 2),loin pain(which started in lower back midline and radiated to groin) and decreased urine output(350ml per day),for which he visited kims hospital.
PAST HISTORY
Not a k/c/o HTN,TB,DM,EPILEPSY, ASTHMA.
Previous surgeries: nephrostomy &left URSL
TREATMENT HISTORY
No relavent treatment history
FAMILY HISTORY
Not significant
PERSONAL HISTORY
Mixed Diet
loss of Appetite
Bowel movements are once in 8-10days
Decreased urine output
Sleep decreased
Addictions -Alcohol occassionally and smoking
No known allergies.
COURSE OF STAY IN HOSPITAL
6 months back ultrasound was done and they diagnosed as RIGHT GROSS and LEFT MODERATE HYDRONEPHROSIS
for which he underwent nephrostomy on 13/10/21(Under LA in Prone position parts Draped and Covered,Intial Puncture was Done With UIP NEEDLE in Post Axillary Line between Illac Crest and Coastal Margin, Track was Dilated With Facial Dilator upto 14 fr).
&left URSL with DJ stenting on 20/10/21(In Lithotomy Position Parts Draped and Covered,
CYSTOSCOPY done with 19tr Cystoscope Left Utereric orifice identified and 0.035 Guide wire is passed into left ureter beyond stone 5/7.5 Ureteroscope Passed in LT Ureter Stone Identifed in upper ureter.Stone was fragmented with Lithotripten.Pnuematic and Laser lithotomy was done.fragments were removed.SFR/26cm DJ stent kept on LT side. Hemostasis secured.14fr FOLEY Kept as PUC procedure Uneventful)
and then discharged and suggested to follow Up next month
After discharge there is no improvement in his condition, so they suggested with 3 sessions of dialysis &Right URSL after a month but due to failure of dialysis through IJV on third session he was still in the hospital
GENERAL EXAMINATION
Patient was conscious, coherent well oriented to time,place , person.Well built and moderately nourished.
PALLOR WAS PRESENT
NO CYANOSIS
NO ICTERUS
NO CLUBBING
NO GENERALISED LYMPHADENOPATHY
NO EDEMA
VITALS::
TEMP AFEBRILE
PR 91bpm
RR 12cpm
BP 130/80mmHg
SYSTEMIC EXAMINATION
1.CVS
**S1 ,S2 heard
**No murmurs.
2.Respiratory system
**Dyspnoea- No
**Wheeze -No
**Position of trachea-Central
**Breath sounds-vesicular
3.ABDOMEN
**Shape of abdomen-scaphoid
**Tenderness-No
** Palpable mass-No
** Liver- Not palpable
**Spleen - Not palpable
**Bowel sounds - No
4.CNS
** No abnormalities detected
Provisional diagnosis :
AKI on CKD secondary to post renal obstruction with B/L ureteric calculi with B/L hydronephrosis.
S/P - Left URSL with DJ stenting done.
Comments
Post a Comment