56 YEAR OLD MALE WITH ABDOMINAL PAIN AND OLIGURIA

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A 56 year old male agricultural labourer by occupation, resident of Muthagudem came to OPD on 13/01/22 with the chief complaints of-

 Pain abdomen since 20 days 

 Vomitings since 20 days

 Fever since 15 days

 Decreased urine output since 15 days

Patient was apparently asymptomatic 3 years ago and then he developed

 B/l loin pain which was sudden in onset gradually progressive and associated with high grade fever.

1 year ago he developed pedal edema upto ankle, decreased urine output, burning micturition, flank pain which is dragging type, radiating towards abdomen, but the patient did not get himself checked due to financial issues. 

3 months ago they visited nalgonda hospital with the same complaints there he was diagnosed with b/l renal calculi. He was given medication after which it got resolved. 

After 2 months he again had developed decreased urine output and b/l pedal edema on and off. Since then he stopped going to work.

On 02/01/22 

He went to a hospital in Nalgonda with C/O fever with chills and rigors and generalised body pains for 3 days

USG report showed 

Right gross pyonephrosis 

Left gross hydronephrosis

Liver hemangioma

For which he was given medication and referred to urologist.

On 08/01/22 

He was taken to a hospital in khammam where his 

USG -

Serum Creatinine - 11.2 mg/dl

On 12/01/22

He was taken to another hospital in Nalgonda with c/o 

b/l loin pain, fever, vomiting, dysuria and reduced urine output.

On CT abd:

Gross HDN of Rt kidney with proximal ureteric calculus of 2 cm.

Lt severe HDN with 2.6 cm mid ureteric calculus

Right kidney and ureter-

Left kidney and ureter-

Patient was counselled about requirement of haemodialysis and was referred to KIMS Narketpally 

He underwent a session of dialysis on 15/01/22

Past history-

Not a k/c/o HTN, DM, TB, Asthma, epilepsy.

Personal history- 

Diet - mixed

Appetite- reduced

Sleep - reduced

Alcoholic since 10 years takes 90 ml everyday

On general physical examination

Patient is conscious coherent and cooperative

Thin built and malnourished

Pallor+ clubbing+

No icterus, cyanosis, lymphadenopathy

Vitals on 13/1/22 

Temp- afebrile 

BP- 140/80 mm hg

PR- 100 bpm

RR- 22 bpm

Spo2- 98 % at RA

GRBS- 116 mg/dl

On systemic examination-

CVS- S1 S2 + No murmurs 

RS- BAE+ No added sounds 

P/A- soft, tender, bilaterally symmetrical, no organomegaly

CNS- No focal neurological deficits

Investigations-

RFT:

Urea- 278

Creat- 16

Na-134

K-6.1

Cl-104

Hemogram:

Hb-7.9

TC- 6,400

PLC- 2,40,000

CUE 

Alb- 1+

PC- 3-4

LFT:

TB- 0.99

DB- 0.28

AST-12

ALT-12

ALP- 174

TP-6.4

Alb-5.5

ABG:

PH- 7.21

Po2- 131

Pco2-14.5

Spo2-96

HCo3-5.7

ECG-

 On the day of admission

Diagnosis:

Post renal AKI secondary to b/l hydronephrosis with refractory hyperkalemia (secondary to renal calculus) with metabolic acidosis

Treatment:

Inj HAI 10 IU in 25%D slow IV/ stat over 30 mins to 1 hour

Inj calcium gluconate 10 ml slow IV a/r 10 mins 

Inj Thiamine 1 amp in 10 ml NS IV over 30 mins/ OD

Inj Sodium bicarbonate 50 meq IV/ stat slowly over 10-20 mins 

Nebulisation with duolin 

IV fluids

Inj lasix 20 mg IV/BD

Inj Zofer 4 mg IV/TID

Tab Orofer XT PO/OD

Tab Nodosis 500 mg PO/BD

Inj Pan 40 mg IV/OD

Tab PCM 650 mg PO/SOS

Salt restriction < 2.4 g/ day

On 19/01/22

LEFT PERCUTANEOUS NEPHROSTOMY UNDER LOCAL ANAESTHESIA IS DONE

One session of haemodialysis done on 19/1/22 

C/o fever with chills , 1 g neomol given.

X ray kidney ureter bladder-

On 20/01/22

SOB reduced 

Fever spikes present 104 F

Cough reduced

O/E -

Patient is c/c/c

Febrile 102.6 F

BP - 100/70

PR - 88bpm

CVS - S1S2+

RS - BAE+

P/A - soft, non tender

Creatinine : 16.3 --> 9.5

Urea : 278 --> 162 --> 217

USG abdomen- 

Findings:

Grade II RPD changes in Lt kidney

Grossly dilated PCS of Rt kidney compressing the renal parenchyma.

Plan - 

To watch for reduction of urea and creatinine