24 yr old male with chronic kidney disease with hydroureteronephrosi
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Nephro new admission
ICU bed no :1
24 year old male who is a labourer , came with chief complaints of
Decreased urine output since 10 days
Shortness of breath since 10 days
Pedal edema since 10 days
Fever since 10 days
HOPI:
patient was apparently asymptomatic 3 years back. Then he developed decreased urine output for which he went to local hospital and scan was done which revealed hydronephrosis .10 days back he had a trauma to the left little finger and dorsum of right foot for which he went to local hospital and dressing was done .10 days back he developed shortness of breath which was insidious in onset and gradually progressive (grade 4 ) aggravated on walking relieved on medication .
Pedal edema since 10 days which was extending till ankle
Fever since 10 days which was continous , not associated with chills and rigour
I/v/o increased serum creatinine dailysis was initiated yesterday
PAST HISTORY:
Not a K/c/o DM , HTN , asthma , epilepsy , BA , TB ,CAD
No past surgical history
No previous blood transfusions
O/E:
Patient is Consious , coherent and co operative
Afebrile
Bp:130/80 mm hg
PR ; 88bpm regular
Cvs : s1 s2 +
Rs : BAE +
P/A: soft , non tender
PROVISIONAL DIAGNOSIS:
Chronic kidney disease with hydroureteronephrosis
Investigations :
On 9/03/22
RFT:
Blood urea: 175 mg/dl
Serum creatinine : 9.3 mg/dl
Sodium : 144 meq/l
Potassium :3.6 meq/l
Chloride:106 meq/ l
ABG:
PH :7.3mmhg
Pco2:7.8mm hg
Po2:123 mmhg
St. Hco3:
Past reports: 3 yrs back
TREATMENT :
Day 0
1.Inj piptaz 4.5 gm IV STAT F/B inj . Piptaz 2.25 gm IV / QID
2.inj clindamycin 600 mg /IV / tid
3.inj pan 40 mg IV /od
4.Tab nodosis 500 mg po/bd
5.Tab shellac 550 mg po / od
6.IVF NS and RL @ 100 ml / hr
7.Inj lasix 40 mg IV / bd if bp is more than 110 mm of hg
8.Tab alpha - D3
11/03/2022
Icu bed no 1
SOAP NOTES
A 24 YEAR OLD MALE
SUBJECTIVE
Decreased shortness of breath compared to yesterday
OBJECTIVE
Pt is c/c/c
Pallor +
Malnutrition +
Dehydration +
No cyanosis, Icterus,Lymphadenopathy
Temp: afebrile
BP: 120/70 mm hg
PR: 86 bpm
CVS: s1, s2 heard
CNS: NAD
RS: BAE+
P/A: soft , non tender
ASSESSMENT-
Chronic kidney disease secondary to hydroureteronephrosis
PLAN OF TREATMENT-
Day 2
1.IV fluids (NS) 30 ml/ hr
2.Inj piptaz 2.25 gm
3.Inj clindamycin 300 mg Iv / tid
4.Inj pan 40 mg iv od
5.Inj lasix 40 mg iv bd
6.Tab nodosis 500 mg bd
7.Tab shellac 500 mg od
8.Cap bio D3 0.25 mg
9.Monitor vitals
