acute kidney injury

Hello all this is J. Mounika,a eighth semester student.This E Log depicts the patient centered approach to learning.

This is an online E Logbook recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent

Date of admission:- 30/09/2023 
A 65 year old female came to OPD with -

CHIEF COMPLAINTS-
fever since 4 days.

HOPI-
patient was apparently asymptomatic 5 days back then she developed fever , which is high grade associated with chills and rigor, continuous type, no diurnal variation, associated with vomitings, cold, cough, loss of appetite, generalised body pains.
H/o vomitings since 5 days , sudden in onset, food as content, non bilious, non projectile, non blood stained, 4 to 5 episodes.
H/o cough since 5 days , which is productive whitish sputum thick consistency.
H/o chest pain left sided associated with SOB grade - 2 according to mMRC .
H/o right hypochondriac abdominal pain since 5 days.
No H/o loose stools, burning micturition.

PAST HISTORY-
K/C/O HTN since 2 years and is on medication (unknown)
Not k/c/o DM, TB, asthma, epilepsy, thyroid disorders.

PERSONAL HISTORY- 

Diet- mixed 

Appetite- normal 

Sleep- adequate 

Bowel and bladder movements- regular 

No known allergies 

Addictions-  used to consume pan one or twice daily but stopped from past 4 months.

Daily routine

She'll wake up around 5:00am and completes her household chores and then have breakfast at 10am and goes for work then will have ,lunch at 2:00pm and comes back from work around 5pm and will have tea .Then she'll have her dinner at 8pm .Mostly all the three times she'll have rice .Then she'll go to bed by 10pm

FAMILY HISTORY- not significant 


GENERAL EXAMINATION-

patient is conscious, coherent, cooperative. Well oriented to time , place and person, moderately built and moderately nourished 

Vitals -

BP- 130/80 mmHg

PR- 92 bpm

RR- 18 cpm

TEMP- 98.2 F

PRESENCE OF PALLOR.

NO SIGNS ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, OEDEMA.


SYSTEMIC EXAMINATION-

1) CVS- S1, S2 heard, no murmurs.

2) RS- BAE present, NVBS 

3) PER ABDOMEN- diffuse tenderness 

 no organomegaly 

4) CNS:

Higher mental functions - intact

Cranial nerves - intact

Motor examination - normal  

Sensory examination:Normal

No meningeal signs. 



PROVISIONAL DIAGNOSIS- 

PYREXIA UNDER EVALUATION WITH LEFT LOWER ZONE COLLAPSE.

PRE RENAL ACUTE KIDNEY INJURY.

HYPOKALEMIA SECONDARY TO GE , KNOWN CASE OF HTN SINCE 2 YEARS.



TREATMENT-

1. INJ. PAN 40MG IV/OD

2. INJ. ZOFER 4MG IV /TID

3. IV. FLUIDS - 2NS @ 75ML/HR  - 1 RL 

4. INJ. NEOMOL 1GM IV/SOS

5. TAB. DOLO 650MG PO/TID

6.  SYP. ASCORIL-LS 15ML/PO/TID.


1/10/2023

1.INJ. PAN 40MG IV/OD

2. INJ. ZOFER 4MG IV/TID

3. IV. FLUIDS - 2NS @ 75ML/HR  - 1 RL 

4. INJ. NEOMOL 1GM IV/SOS

5.INJ.MONOCEF -1GM IV/BD

6. TAB. DOLO 650MG PO/TID

7.  SYP. ASCORIL-LS 15ML/PO/TID.


2/10/2023

1.INJ. PAN 40MG IV/OD

2. INJ. ZOFER 4MG IV/TID

3. IV. FLUIDS - 2NS @ 75ML/HR - 1 RL 

4. INJ. NEOMOL 1GM IV/SOS

5.INJ.KCL 2AMPULES IN 500ML NS IV SLOWLY OVER 5-6HOURS

6.TAB.PCM 650MG PO/TID

7.TAB.AMLODIPINE 5MG PO/OD

8.SYP.ASCORIL-LS 15ML/PO/TID.

9.INJ.CIPROFLOXACIN 200MG IV/BD

10.TAB.SPORLAC DS PO/TID


3/10/2023

1.INJ. PAN 40MG IV/OD

2. INJ. ZOFER 4MG IV/TID

3. IV. FLUIDS - 2NS @ 75ML/HR - 1 RL 

4. INJ. PCM 1GM IV/SOS

5.INJ.REDOTRIL  100MG PO/BD

6.TAB.PCM 650MG PO/TID

7.TAB.AMLODIPINE 5MG PO/OD

8.SYP.ASCORIL-LS 15ML/PO/TID.

9.INJ.CIPROFLOXACIN 200MG IV/BD

10.TAB.SPORLAC DS PO/TID

11.INJ.METROGYL 500MG IV/TID


4/10/2023

1.INJ. PAN 40MG IV/OD

2. INJ. ZOFER 4MG IV/TID

3. IV. FLUIDS - 2NS @ 75ML/HR - 1 RL 

4. INJ. PCM 1GM IV/SOS

5.INJ.REDOTRIL 100MG PO/BD

6.TAB.PCM 650MG PO/TID

7.TAB.AMLODIPINE 5MG PO/OD

8.SYP.ASCORIL-LS 15ML/PO/TID.

9.INJ.CIPROFLOXACIN 200MG IV/BD

10.TAB.SPORLAC DS PO/TID

11.INJ.METROGYL 500MG IV/TID


5/10/2023

1.INJ. PAN 40MG IV/OD

2. INJ. ZOFER 4MG IV/TID

3. IV. FLUIDS - 2NS @ 75ML/HR - 1 RL 

4. INJ. PCM 1GM IV/SOS

5.INJ.REDOTRIL 100MG PO/BD

6.TAB.PCM 650MG PO/TID

7.TAB.AMLODIPINE 5MG PO/OD

8.SYP.ASCORIL-LS 15ML/PO/TID.

9.INJ.CIPROFLOXACIN 200MG IV/BD

10.TAB.SPORLAC DS PO/TID

11.INJ.METROGYL 500MG IV/TID


6/10/2023

1.INJ. PAN 40MG IV/OD

2. INJ. ZOFER 4MG IV/TID

3. IV. FLUIDS - 2NS @ 75ML/HR - 1 RL 

4. INJ. PCM 1GM IV/SOS

5.TAB.AMLODIPINE 5MG PO/OD

6.TAB.PCM 650MG PO/QPD

7.SYP.ASCORIL-LS 15ML/PO/TID.

8.INJ.DOXYCYCLINE 100MG IV/BD

9.TAB.SPORLAC DS PO/TID

10.INJ.SODIUM BICARBONATE 25MCG IV STAT


7/10/2023

1.IV. FLUIDS - 2NS @ 75ML/HR - 1 RL

2.INJ.DOXYCYCLINE 100MG IV/BD

3.INJ.FALCIGO 120MG IV 

4.INJ.SODIUM BICARBONATE 50MCG IV STAT 50 MCG IN 500ML NS OVER 8HOURS

5.INJ.PCM 1G IV/SOS

6.INJ.ZOFER 4MG IV/SOS

7.TAB. PCM 650MG PO/QID

8.TAB.NODOSIS 500MG PO/QID

9.TAB.AMLODIPINE 5MG PO/OD

10.INJ.PAN40MG IV/OD


8/10/2023

1.IV. FLUIDS - 2NS @ 75ML/HR - 1 RL

2.INJ.DOXYCYCLINE 100MG IV/BD

3.INJ.FALCIGO 120MG IV 

4..INJ.PCM 1G IV/SOS

5.INJ.ZOFER 4MG IV/SOS

6.TAB. PCM 650MG PO/QID

7.INJ.PAN40MG IV/OD

8.TAB.NODOSIS 500MG PO/QID

9.TAB.AMLODIPINE 5MG PO/OD


9/10/2023

1.IV. FLUIDS - 2NS @ 75ML/HR - 1 RL

2.INJ.DOXYCYCLINE 100MG IV/BD

3.INJ.METHYLPREDISOLONE 1GM IV/OD

4.INJ.PAN40MG IV/OD

5.TAB.NODOSIS 500MG PO/QID

6.INJ.LASIX 20MG IV/BD

7.INJ.KCL 2AMPULES IN 500ML NS IV SLOWLY OVER 5-6HOURS


11/10/2023

1.IV. FLUIDS - 2NS @ 75ML/HR - 1 RL

2.INJ.DOXYCYCLINE 100MG IV/BD

3.INJ.METHYLPREDISOLONE 1GM IV/OD

4.INJ.PAN40MG IV/OD

5.TAB.NODOSIS 500MG PO/QID

6.INJ.LASIX 20MG IV/BD

7.SYP.ASCORIL-LS 10ML/PO/TID.


12/10/2023

1.IV. FLUIDS - 2NS @ 75ML/HR - 1 RL

2.INJ.DOXYCYCLINE 100MG IV/BD

3.INJ.METHYLPREDISOLONE 1GM IV/OD

4.INJ.PAN40MG IV/OD

5.TAB.NODOSIS 500MG PO/QID

6.INJ.LASIX 20MG IV/BD

7.SYP.ASCORIL-LS 10ML/PO/TID.


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