55/M WITH AKI (ATN) ON CKD , HFpEF, RHEUMATOID ARTHRITIS.
HOPI:- Patient was apparently asymptomatic till 1997 when he had fall from a current pole after which he had injury to left upperlimb , lowerlimb and lowerback for which he started using painkillers daily till 1 month back.
6 years back he started developing pedal edema in B/L lowerlimbs ,pitting type extending upto both the knees.
Patient gives h/o trauma 1 month back to right lowerlimb at the ankle due to bike accident which got infected for which he was prescribed some antibiotics. The wound didnot subside even after taking antibiotics.
15 days ago i.e. on 20.7.2021 he developed sudden onset SOB for which he was taken to hospital there he was given oxygen support for his SOB. There the doctors told him that his serum creatinine levels are elevated and advised him dialysis. On 26.7.2021 while patient is being prepared for cvp line he suffered from cardiac arrest and was resuscitated.
His 1st dialysis was done on 26.7.2021 .
And on 26th his for his knee joints swelling doctors performed a procedure and drained 150ml of serosanguinous fluid from each of the knee joints. And again they performed same procedure on 30.7.2021 and drained 80ml fluid from right knee joint and 50ml from left knee joint.From then he underwent dilaysis for 6 times (6th dialysis was done on 2.8.2021).
After his 6th dialysis patient was taken home. After going home patient develeoped decreased urine output and for the same reason he was brought to our casualty.
PERSONAL HISTORY:-
Diet is mixed.
Appetite is normal.
Sleep is adequate.
Bladder movements- decreased urine output
Bowel movements are regular.
Addictions- History of alcohol intake since past 25 years.
ON EXAMINATION:-
Patient is conscious, coherent and cooperative.
No signs of pallor, icteurs, cyanosis, Lymphadenopathy .
Clubbing is present.
Edema is present-B/L lowerlimbpitting type extending upto both the knees.
Vitals:-
PR=93bpm
BP=120/80mmhg
RR=24cpm
GRBS=136mg/dl
TEMPERATURE =98.6F
SPO2=98% on 4L of O2
CVS- S1,S2 +, no murmurs
RS- BAE+,
B/L inspiratory crepts in ISA and IAA
P/A- Soft, NT, bowel sounds present
CNS-NAD
RENAL AKI (ATN) ON CKD WITH HFpEF (EF=52%)
WITH UTI (FUNGAL ETIOLOGY)
WITH ASSYMETRICAL RHEUMATOID ARTHRITIS
WITH GRADE 2 BED SORE
WITH INFECTIVE SYNOVITIS OF B/L KNEE
5 SESSIONS OF HEMODIALYSIS DONE.
URINE C/S- FEW PUS CELLS AND BUDDING YEAST CELLS ARE SEEN
BLOOD C/S- NO GROWTH AFTER 1 WEEK INCUBATION
TREATMENT:-
ANTECEDENT CAUSE OF DEATH- AKI (ATN) on CKD with HFpEF with UTI with B/L Infective synovitis of knee with refractory hypotension.
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DEPARTMENT
OF GENERAL-MEDICINE |
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DISCHARGE
SUMMARY *** |
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Name
: M NARSI
REDDY |
IPID
: 202117763 |
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UHID : 20210803426 |
Pay
Type : Credit(AROGYA
SREE) |
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Age/Gender : 55 Years/Male |
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Address : |
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Discharge Type: Expired on 15.8.2021 |
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Admission
Date: 04/08/2021 01:14 PM |
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Discharge Date
Date:15.8.2021
Ward:AMC
Unit:3
Name of Treating Faculty
DR. MADHUMITHA (INTERN)
DR. SRIRAM (INTERN)
DR. NAVEEN (INTERN)
DR. SELINA(INTERN)
DR. K. MANASA (INTERN)
DR. MAHITH (INTERN)
DR. PRADEEP (PGY1)
DR. SUSHMITHA (PGY2)
DR. HAREEN (SR)
DR. PRAVEEN NAIK (ASSOCIATE PROFESSOR)
DR. RAKESH BISWAS (HOD)
Diagnosis
RENAL AKI (ATN) ON CKD WITH HFpEF (EF=52%)
WITH UTI (FUNGAL ETIOLOGY)
WITH ASSYMETRICAL RHEUMATOID ARTHRITIS
WITH GRADE 2 BED SORE
WITH INFECTIVE SYNOVITIS OF B/L KNEE
5 SESSIONS OF HEMODIALYSIS DONE.
Case History and Clinical Findings
55/M mechanic R/O kondapakagudem was brought to casualty on 4.8.2021 with complaints of h/o decreased urine output since 3 days. HOPI:- Patient was apparently asymptomatic till 1997 when he had fall from a current pole after which he had injury to left upperlimb , lowerlimb and lowerback for which he started using painkillers daily till 1 month back. 6 years back he started developing pedal edema in B/L lowerlimbs ,pitting type extending upto both the knees. 6 years back he also developed B/L knee joint pains and swelling. Patient gives h/o trauma 1 month back to right lowerlimb at the ankle due to bike accident which got infected for which he was prescribed some antibiotics. The wound didnot subside even after taking antibiotics. 15 days ago i.e. on 20.7.2021 he developed sudden onset SOB for which he was taken to hospital there he was given oxygen support for his SOB. There the doctors told him that his serum creatinine levels are elevated and advised him dialysis. On 26.7.2021 while patient is being prepared for cvp line he suffered from cardiac arrest and was resuscitated. His 1st dialysis was done on 26.7.2021 . And on 26th his for his knee joints swelling doctors performed a procedure and drained 150ml of serosanguinous fluid from each of the knee joints. And again they performed same procedure on 30.7.2021 and drained 80ml fluid from right knee joint and 50ml from left knee joint.From then he underwent dilaysis for 6 times (6th dialysis was done on 2.8.2021). After his 6th dialysis patient was taken home. After going home patient develeoped decreased urine output and for the same reason he was brought to our casualty.
PERSONAL HISTORY:- Diet is mixed. Appetite is normal. Sleep is adequate. Bladder movementsdecreased urine output Bowel movements are regular.
Addictions- History of alcohol intake since past 25 years.
PAST HISTORY:-Not a k/c/o HTN, DM,TB, ASTHMA, EPILEPSY, CAD ON
EXAMINATION:- Patient is conscious, coherent and cooperative.
No signs of pallor, icteurs, cyanosis, Lymphadenopathy .
Clubbing is present.
Edema is present-B/L lowerlimbpitting type extending uptoboth the knees.
Vitals:- PR=93bpm
BP=120/80mmhg RR=24cpm
GRBS=136mg/dl
TEMPERATURE =98.6F SPO2=98% on 4L of O2
CVS- S1,S2 +, no murmurs
RS-BAE+, B/L inspiratory crepts in ISA and IAA
P/A- Soft, NT, bowel sounds present
CNS-NAD
Investigation
ABG:-PH=7.36
PCO2=44.4
PO2=73.8
HCO3=24.9
St HCO3=24.4O2
Sat=92.1
BLOOD UREA=75mg/dl->87mg/dl->93
SERUM CREATININE = 5.4->5.8->5.9
SERUM ELECTROLYTES:-Sodium=131 mEq/L->132mEq/L->137
Potassium =3.4 mEq/L->3.5mEq/L->3.9
Chloride = 94 mEq/L->95mEq/L>102
USG ABDOMEN:-CholelithiasisIncreased anteroposterior diameter of kidneys with CMD partially lost, altered echotexture. ? AKI on CKD.
2D ECHO:-Mild global hypokinesia,EF= 52Mild LV dysfunction,IVC size - 1.6cm (mild dilated).
USG B/L KNEE JOINT- DIFFUSE SYNOVIAL THICKENING WITH MINIMAL JOINT EFFUSION IN RIGHT KNEE JOINT LOCULATED COLLECTION (2.8x3.6CM) NOTED ALONG MEDIAL ASPECT OF LEFT KNEE JOINT. F/S/O INFECTIVE SYNOVITIS.
URINE C/S- FEW PUS CELLS AND BUDDING YEAST CELLS ARE SEEN
BLOOD C/S- NO GROWTH AFTER 1 WEEK INCUBATION
Investigations
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Name |
Value |
Range |
Name |
Value |
Range |
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HBsAg-RAPID
04- Negative
Kit Name: 08-2021
01:34:PM Abon |
Anti HCV Antibodies Non Reactive Kit - RAPID 04-08-2021 Name:Life
Band 01:34:PM |
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BLOOD UREA
04- 75 mg/dl 42-12 mg/dl 08-2021 01:34:PM |
SERUM 5.4 mg/dl 1.3-0.9 mg/dl CREATININE 04-08- 2021 01:34:PM |
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SERUM ELECTROLYTES (Na, K, C
l) 04-08-2021 01:34:PM SODIUM 131
mEq/L 145-136 mEq/L POTASSIUM 3.4
mEq/L 5.1-3.5 mEq/L CHLORIDE 94
mEq/L 98-107 mEq/L |
LIVER FUNCTION TEST (LFT) 04-08-2021 01:34:PM Total Bilurubin 1.29 mg/dl 1-0
mg/dl Direct Bilurubin 0.28 mg/dl 0.2-0.0
mg/dl SGOT(AST) 21
IU/L 35-0 IU/L SGPT(ALT) 10 IU/L 45-0
IU/L ALKALINE 636
IU/L 128-53 IU/L PHOSPHATE TOTAL PROTEINS 6.0 gm/dl 8.3-6.4
gm/dl ALBUMIN 2.6
gm/dl 5.2-3.5 gm/dl A/G RATIO 0.78 |
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COMPLETE URINE EXAMINATION (CUE) 04-08-2021 01:34:PM COLOUR Slightly
brownish APPEARANCE Slightly
cloudy REACTION Acidic SP.GRAVITY 1.010 ALBUMIN +++ SUGAR Nil BILE SALTS Positive BILE PIGMENTS Positive PUS CELLS Plenty EPITHELIAL CELLS 1-2 RED BLOOD CELLS 8-12 CRYSTALS Nil CASTS Nil AMORPHOUS Absent DEPOSITS OTHERS Fungal
hyphae seen. |
ABG 04-08-2021 01:36:PM PH 7.36 PCO2 44.4 PO2 73.8 HCO3 24.9 St.HCO3 24.4 BEB 0.0 BEecf 0.2 TCO2 52.9 O2 Sat 92.1 O2 Count 11.6 |
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SARS-COV-2 Negative Qualitative PCR 05- 08-2021 10:51:AM |
ABG 05-08-2021 11:00:PM PH 7.35 PCO2 37.2 PO2 125 HCO3 20.4 St.HCO3 21.0 BEB -4.1 BEecf -4.1 TCO2 44.6 O2 Sat 97.3 O2 Count 9.5 |
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RFT
05-08-2021 11: UREA CREATININE URIC ACID CALCIUM PHOSPHOROUS SODIUM POTASSIUM CHLORIDE |
00:PM 71 mg/dl 4.2 mg/dl 7.0 mg/dl 10.2 mg/dl 4.3 mg/dl 132 mEq/L 3.6 mEq/L 97 mEq/L |
42-12 mg/dl 1.3-0.9 mg/dl 7.2-3.5 mg/dl 10.2-8.6 mg/dl 4.5-2.5 mg/dl 145-136 mEq/L 5.1-3.5 mEq/L 98-107
mEq/L |
RFT
07-08-2021 05: UREA CREATININE URIC ACID CALCIUM PHOSPHOROUS SODIUM POTASSIUM CHLORIDE |
44:AM 87 mg/dl 5.8 mg/dl 4.3 mg/dl 10.1 mg/dl 4.4 mg/dl 132 mEq/L 3.5 mEq/L 95 mEq/L |
42-12 mg/dl 1.3-0.9 mg/dl 7.2-3.5 mg/dl 10.2-8.6 mg/dl 4.5-2.5 mg/dl 145-136 mEq/L 5.1-3.5 mEq/L 98-107
mEq/L |
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BLOOD UREA 09- 08-2021 06:16:AM |
93 mg/dl |
42-12
mg/dl |
SERUM 5.9 mg/dl CREATININE 09-08- 2021 06:16:AM |
1.3-0.9
mg/dl |
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SERUM ELECTROLY SODIUM POTASSIUM CHLORIDE |
TES (Na,
K, C l) 09-0 137 mEq/L 3.9 mEq/L 102 mEq/L |
8-2021 06:16:AM 145-136 mEq/L 5.1-3.5 mEq/L 98-107
mEq/L |
SERUM ELECTROLY SODIUM POTASSIUM CHLORIDE |
TES (Na,
K, C l) 11-0 130 mEq/L 3.4 mEq/L 93 mEq/L |
8-2021 12:15:AM 145-136 mEq/L 5.1-3.5 mEq/L 98-107
mEq/L |
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ABG
11-08-2021 06: PH PCO2 PO2 HCO3 St.HCO3 BEB BEecf
TCO2 O2 Sat O2 Count |
37:PM 7.36 21.5 101 11.9 16.1 -11.1 -12.5 22.4 95.2 24.0 |
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ABG
12-08-2021 05: PH PCO2 PO2 HCO3 St.HCO3 BEB BEecf
TCO2 O2 Sat O2 Count |
27:AM 7.41 39.4 56.7 24.5 24.7 0.4 0.4 53.3 86.5 8.0 |
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RFT
12-08-2021 05: |
27:AM |
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UREA |
46 mg/dl |
42-12
mg/dl |
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CREATININE |
4.4 mg/dl |
1.3-0.9
mg/dl |
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URIC ACID |
3.2 mg/dl |
7.2-3.5
mg/dl |
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CALCIUM |
10.0 mg/dl |
10.2-8.6
mg/dl |
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PHOSPHOROUS |
3.5 mg/dl |
4.5-2.5
mg/dl |
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SODIUM |
134 mEq/L |
145-136
mEq/L |
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POTASSIUM |
3.4 mEq/L |
5.1-3.5
mEq/L |
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CHLORIDE |
98 mEq/L 98-107
mEq/L |
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Treatment
Given(Enter only Generic Name)
TREATMENT:-DATE- 4.8.2021
Inj. Piptaz 4.5g IV/Stat -> 2.25g IV/TID
Tab. Fluconazole 100mg PO/OD
Fluid restriction <1lt/day
Protein powder 2tbsp in 100ml milk daily
Temparature charting 4th hrly
PR,BP,SPO2,GRBS monitoring 2nd hrly
DATE-5.8.2021
PR=90bpm
BP=130/80mmhg
CVS-S1,S2+
RS-BAE+
P/A-soft,non tender
CNS-NAD
Fluid restriction <2L/day
Salt restriction <2g/day
Inj.Piptaz 2.25g IV/TID
Inj. Pan 40mg IV/OD
Inj. Lasix 40mg IV/BD
Tab. Fluconazole 100mg PO/OD
Protein powder 2tbsp in 100ml milk BD
Temparature charting 4th hrly
PR,BP,SPO2,GRBS monitoring 2nd hrly
DATE-6.8.2021
PR=96bpm
BP=130/70mmhg
CVS-S1,S2+
RS-BAE+
P/A-soft,non tender
CNS-NAD
Fluid restriction <2L/day
Salt restriction <2g/day
Inj. Piptaz 2.25g IV/TID
Inj. Pan 40mgIV/OD
Inj. Lasix 40mg IV/BD
Tab. Fluconazole 100mg PO/OD
Protein powder 2tbsp in 100ml milkBD
Temparature charting 4th hrly
PR,BP,SPO2,GRBS monitoring 2nd hrly
DATE-7.8.2021
PR=92bpm
BP=120/80mmhg
CVS-S1,S2+
RS-BAE+
P/A-soft,non tender
CNS-NAD
Fluid restriction <2L/day
Salt restriction <2g/day
Inj. Piptaz 2.25g IV/TID
Inj. Pan 40mg IV/OD
Inj. Lasix 40mgIV/BD
Tab. Fluconazole 100mg PO/OD
Tab. Ultracet 1/2 tab QID
Protein powder 2tbsp in 100ml milkBD Temparature charting 4th hrly PR,BP,SPO2,GRBS monitoring 2nd hrly
DATE-8.8.2021
PR=96bpm
BP=130/70mmhg
CVS-S1,S2+
RS-BAE+
P/A-soft,non tender
CNS-NAD
Fluid restriction <2L/day
Salt restriction <2g/day
Inj. Piptaz 2.25g IV/TID
Inj. Pan 40mg IV/OD
Inj. Lasix 40mgIV/BD
Tab. Fluconazole 100mg PO/OD
Tab. Ultracet 1/2 tab QID
Protein powder 2tbsp in 100ml milk
BDTemparature charting 4th hrly
PR,BP,SPO2,GRBS monitoring 2nd hrly
DATE-9.8.2021
PR=90bpm
BP=130/80mmhg
CVS-S1,S2+
RS-BAE+
P/A-soft,non tender
CNS-NAD
Fluidrestriction <2L/day
Salt restriction <2g/day
Inj. Piptaz 2.25g IV/TID
Inj. Pan 40mg IV/OD
Inj. Lasix 40mgIV/BD
Tab. Fluconazole 100mg PO/OD
Tab. Ultracet 1/2 tab QID
Protein powder 2tbsp in 100ml milk
BDTemparature charting 4th hrly PR,BP,SPO2,GRBS monitoring 2nd hrly
2 SESSIONS OF HEMODIALYSIS DONE.
DATE- 10.8.2021
SOAP NOTES :
SUBJECTIVE:Pt c/o left elbow joint pain,b/l knee joint pain and swelling
OBJECTIVE-
Temperature-98 F
Bp-90/60 mmhg
PR- 92bpm
RR -17 cpm
ASSESSMENT-RENAL AKI (ATN) ON CKD ANALGESIC
NEPHROPATHY WITH UTI (FUNGAL
ETIOLOGY) RIGHT LOWERLIMB
CELLULITISHFpEFCHOLELITHIASIS
PLAN OF CARE-1.Fluid restriction <2L/day
2.Salt restriction<2g/day
3.Inj. Piptaz 2.25g IV/TID
4.Inj. Pan 40mg IV/OD
5.Inj. Lasix 40mg IV/BD
6.Tab. Fluconazole100mg PO/OD
7.Protein powder 2tbsp in 100ml milk BD.
8. 3rd dialysis done on 9/8/21(1st on 5/8/21,2nd on 7/8/21)
DATE:-11.8.2021
SOAP NOTES:
SUBJECTIVE:Pt c/o left elbow joint pain,b/l knee joint pain and swelling
OBJECTIVE
Temperature-98 F
Bp-100/60 mmhg
PR- 90bpm
RR -17 cpm
ASSESSMENT-RENAL AKI (ATN) ON CKD ANALGESIC NEPHROPATHY WITH UTI (FUNGAL ETIOLOGY) RIGHT LOWERLIMB CELLULITISHFpEFCHOLELITHIASIS
PLAN OF CARE-1.Fluid restriction <2L/day
2.Salt restriction <2g/day
3.Tab.Augmentin 625mg PO/BD
4.Inj. Pan 40mgIV/OD
5.Inj. Lasix 40mg IV/BD
6.Tab. Fluconazole 100mg PO/OD
7.Protein powder 2tbsp in 100ml milk BD.
Date- 12.8.2021
SOAP NOTES:
SUBJECTIVE:Pt c/o left elbow joint pain,b/l knee joint pain and swelling
OBJECTIVETemperature-98 FBp-100/60 mmhgPR- 90bpmRR -17 cpm
ASSESSMENT-RENAL AKI (ATN) ON CKD ANALGESIC NEPHROPATHY WITH UTI (FUNGAL ETIOLOGY) RIGHT LOWERLIMB CELLULITISHFpEFCHOLELITHIASIS
PLAN OF CARE-
1.Fluid restriction <2L/day
2.Salt restriction <2g/day
3.Tab.Augmentin 625mg PO/BD
4.Inj. Pan 40mg IV/OD
5.Inj. Lasix 40mgIV/BD
6.Tab. Fluconazole 100mg PO/OD
7.Protein powder 2tbsp in 100ml milk BD.
8. Tab Ultracet 1/2 tab QID
4 SESSIONS OF HD DONE 4TH SESSION DONE ON 11.8.2021
•Date- 13.8.2021
SOAP NOTES:
SUBJECTIVE:Pt c/o left elbow joint pain,b/l knee joint pain and swelling
OBJECTIVE-
Temperature-98 F
Bp-100/60 mmhg
PR- 96bpm
RR -17 cpm
ASSESSMENT-
RENAL AKI (ATN) ON CKD WITH HFpEF (EF=52%)
WITH UTI (FUNGAL ETIOLOGY)
WITH ASSYMETRICAL RHEUMATOID ARTHRITIS
WITH GRADE 2 BED SORE
WITH INFECTIVE SYNOVITIS OF B/L KNEE
5 SESSIONS OF HEMODIALYSIS DONE.
PLAN OF CARE-1.Fluid restriction <2L/day
2.Salt restriction <2g/day
3.Tab.Augmentin 625mg PO/BD (D3)
4.Inj. Pan 40mg IV/OD
5.Inj. Lasix 40mg IV/BD
6.Tab. Fluconazole 100mg PO/OD(D10)
7.Protein powder 2tbsp in 100ml milk BD.
8. Tab Ultracet 1/2 tab QID
5 SESSIONS OF HD DONE 5TH SESSION DONE ON 14.8.2021
COURSE IN THE HOSPITAL- THIS IS A CASE OF 55/M WITH RENAL AKI (ATN) ON CKD WITH HFpEF(EF=52%)
WITH UTI (FUNGAL ETIOLOGY)
WITH ASSYMETRICAL RHEUMATOID
ARTHRITISWITH GRADE 2 BED SOREWITH INFECTIVE SYNOVITIS OF B/L KNEE.
PATIENT WAS ADMITTED ON 4.8.2021 AND WAS TREATED WITH
1.Fluid restriction <2L/day
2.Salt restriction <2g/day
3.Tab.Augmentin 625mg PO/BD (D3)
4.Inj. Pan 40mg IV/OD
5.Inj. Lasix 40mg IV/BD
6.Tab.Fluconazole 100mg PO/OD(D10)
7.Protein powder 2tbsp in 100ml milk BD.
8. Tab Ultracet 1/2 tab QID
5 SESSIONS OF HD DONE 5TH SESSION DONE ON 14.8.2021.
DEATH SUMMARY:-
This is 55/M came to casualty on 4.8.2021 with complaints of decreased urine output since 2 days amd SOB since 2 days diagnosed to be
15 days back patient had sidden onset SOB and got 6 sessions of dialysis done in the outside hospital, ? Post CPR stauts during cvp line insertion ( no record available ). With B/L knee hemarthrosis (aspiration done).
From 2 days patient was tachypneic, D-Dimer is 10mg/ml.
On 15.8.2021 patient suddenlt had falling saturation , Pulse and BP not recordable.
CPR was initiated, patient was intuabated ET 7.00mm. Inj. Adrenaline was given , according to 2020 AHA guidelines 6 cycles of CPR was done.
Despite of all resuscitation measures patient couldnot be revived and was declared dead at 4.24pm on 15.8.2021.
ANTECEDENT CAUSE OF DEATH- AKI (ATN) on CKD with HFpEF with UTI with B/L Infective synovitis of knee with refractory hypotension.
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