Renal AKI with Rt Synpneumonic effusion

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I've 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 a diagnosis and treatment plan.

Name :- kattekola sathwik 

Roll no:- 75 

Case report 

70 yr old male farmer hailing from rural telangana has presented to the OPD with c/o decrrsed urine output since 15 days 

HOPI

Patient was apparently asymptomatic 15 days ago then he noticed that his urine output has been decreasing. It is associated with burining micturition. No H/o Pyuria, dysuria,pain abdomen, loin pain. 

Reddish discoulouration of Urine present Today 

He also Complains of an Episode of Non bilious vomiting Today.

The patient also reports that 2 days ago he had an episode of dizziness for which he went to a local hospital where he was diagnosed as BPPV and was managed conservatively. 

Past History 

The patient gives History of Haemodialysis About 10 yrs ago after He had fever with abdominal distension 

He is a K/c/O CVA 15 yrs ago 

K/c/o HTN Since 10 yrs initially on T. LOSAR H AND PRESENTLY ON T.TELMA H PO OD 

Not a K/c/o DM , Asthma, TB, Epilepsy, CAD , Thyroid disorders 

Personal History 

Appetite :- Normal

Diet ,:Mixed

Bowel : regular 

Sleep :- Adequate 

Addictions :- 

 Regular Alcoholic stopped 12 yrs ago 

Regualar smoker - Used to smoke 2-3 beedis per day 

Stopped 12 yrs ago 

General Examination

Patient is C/c/C 

No pallor, icterus, cyanosis, Lymphadenopathy, Pedal edema 

Temp :- 98.5F

Bp :- 170/110mmHg 

PR:- 92 bpm

Spo2 :- 99 % @RA 

CVS :- S1s2+ No murmurs 

RS :- BAE+ NVBS + 

PA:- Soft NT 

CNS :- NFND

Investigations 

Hemogram 

RBS 

Blood Urea

LDH

Serum creatinine

Serum electrolytes

Urine protien / Creatinine ratio

USG abdomen and pelvis 

ECG 

Chest x ray :- 16.03.2023 1am 

USG chest 

Urology Referral 

At 7 pm on 16.3.2023 Under strict aseptic conditions ,under USG GUIDANCE, 2% lignocaine was Instilled and 20cc syringe was placed in 6th intercostal space in Right Interscapular area and 20mL straw colour fluid was aspirated

Pleural Fluid Cytology 

17/3/2023

18/3/2023

19/3/2023

20/3/2023

Treatment 

1. IV FLUIDS @75 ML/HOUR 

SOAP notes :-16/3/2023

Date of admission 16/3/23

70 yr old male has come to casuality with c/o decreased Urine Output since 15 days 

S 

C/O decreased Urine output 

O

O/E

Pt is C/C/C

BP:150/100mmHg

PR:74bpm

RR:16cpm

Temp:98F

Spo2:98% At room air

CVS:S1S2 heard

RS:BAE+NVBS heard

P/A-soft,non tender

CNS:NFND 

A

POST RENAL AKI SECONDARY TO GRADE 3 PROSTATOMEGALY WITH HYPONATREMIA WITH ANEMIA UNDER EVALUATION WITH K/C/O HTN SINCE 10.YRS 

P

1.Inj.ZOFER IV SOS 

2. INJ PANTOP 40 MG IV OD 

3.Tab.CINOD 10 MG P9 BD

4.Tab.URIMAX D PO HS 

5.SYP CITRALKA 15ml in One glass of Water PO TID

Date :- 17/3/2023

70 yr old male has come to casuality with c/o decreased Urine Output since 15 days 

S 

C/O decreased Urine output 

O

O/E

Pt is C/C/C

BP:110/80mmHg

PR:84bpm

RR:18cpm

Temp:98F

Spo2:96% At room air

GRBS :- 103 mg/dL 

CVS:S1S2 heard

RS:BAE+NVBS heard

P/A-soft,non tender,BS+

CNS:NFND 

A

 RENAL AKI ON ?CKD WITH GRADE 3 PROSTATOMEGALY WITH HYPONATREMIA (TRUE, HYPOVOLEMIC) WITH MODERATE PLEURAL EFFUSION (EXUDATIVE ON RIGHT SIDE ) WITH ANEMIA UNDER EVALUATION WITH K/C/O HTN SINCE 10.YRS 

P

1.Inj.ZOFER IV SOS 

2. INJ PANTOP 40 MG IV OD 

3.Tab.CINOD 10 MG P9 BD

4.Tab.SILDOCIN D PO OD 

5.SYP CITRALKA 15ml in One glass of Water

18/3/2023

S 

C/O decreased Urine output 

O

O/E

Pt is C/C/C

BP:140/90mmHg

PR:84bpm

RR:18cpm

Temp:98F

Spo2:96% At room air

GRBS :- 86mg/dL                       I/O:-3400/1100 ml 

CVS:S1S2 heard

RS:BAE+NVBS heard

P/A-soft,non tender,BS+

CNS:NFND 

A

 RENAL AKI ON ?CKD  WITH GRADE 3 PROSTATOMEGALY WITH HYPONATREMIA (TRUE, HYPOVOLEMIC)(RESOLVED) WITH MODERATE PLEURAL EFFUSION (EXUDATIVE ON RIGHT SIDE ) WITH ANEMIA UNDER EVALUATION WITH K/C/O HTN SINCE 10.YRS 

P

1.Inj.ZOFER IV SOS 

2. INJ PANTOP 40 MG IV OD 

3.Tab.CINOD 10 MG P9 BD

4.Tab.SILDOCIN D PO OD 

5.SYP CITRALKA 15ml in One glass of Water PO TID           

6.Syp.LACTULOSE 15ML PO HS

19/3/2023

S 

C/O decreased Urine output 

O

O/E

Pt is C/C/C

BP:140/90mmHg

PR:84bpm

RR:18cpm

Temp:98F

Spo2:96% At room air

GRBS :- 86mg/dL                       I/O:-3050/1050 ml 

CVS:S1S2 heard

RS:BAE+NVBS heard

P/A-soft,non tender,BS+

CNS:NFND 

A

 RENAL AKI ON ?CKD  WITH GRADE 3 PROSTATOMEGALY WITH HYPONATREMIA (TRUE, HYPOVOLEMIC)(RESOLVED) WITH MODERATE PLEURAL EFFUSION (EXUDATIVE ON RIGHT SIDE ) WITH ANEMIA UNDER EVALUATION WITH K/C/O HTN SINCE 10.YRS 

P

1.Inj.ZOFER IV SOS 

2. INJ PANTOP 40 MG IV OD 

3.Tab.CINOD 10 MG P9 BD

4.Tab.SILDOCIN D PO OD 

5.SYP CITRALKA 15ml in One glass of Water PO TID           

6.Syp.LACTULOSE 15ML PO HS

20/3/2023

S 

C/O decreased Urine output 

O

O/E

Pt is C/C/C

BP:140/90mmHg

PR:80bpm

RR:22cpm

Temp:98F

Spo2:96% At room air

GRBS :- 86mg/dL                       I/O:-2900/1400 ml 

CVS:S1S2 heard

RS:BAE+NVBS heard

P/A-soft,non tender,BS+

CNS:NFND 

A

 RENAL AKI ON ?CKD  WITH GRADE 3 PROSTATOMEGALY WITH HYPONATREMIA (TRUE, HYPOVOLEMIC)(RESOLVED) WITH MODERATE PLEURAL EFFUSION (EXUDATIVE ON RIGHT SIDE ) WITH ANEMIA UNDER EVALUATION WITH K/C/O HTN SINCE 10.YRS 

P

1.Inj.ZOFER IV SOS 

2. INJ PANTOP 40 MG IV OD 

3.Tab.CINOD 10 MG P9 BD

4.Tab.SILDOCIN D PO OD 

5.SYP CITRALKA 15ml in One glass of Water PO TID           

6.Syp.LACTULOSE 15ML PO HS