AKI with MODS

AKI with MODS

This is an online E logbook to discuss our patients' de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from the available global online community of experts intending to solve those patients clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome. 

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.

Following is the view of my case :

CASE PRESENTATION:

A 32 year old male who is a lorry driver by occupation, resident of nalgonda has come to the casualty with the chief complaints of

  • Pain abdomen since 10 days
  • SOB since 10 days
  • B/L pedal edema since 10 days
  • Decreased urine output since yesterday
History of presenting illness:
Patient was apparently asymptomatic 10 days ago followed by he developed B/L pedal edema which is of Pitting type initially above knees and then progressed till thigh and later to abdomen followed by which he developed abdominal tightness, pain abdomen and difficulty breathing since 10 days
Pain in the abdomen was diffuse to whole abdomen and gradually increased in intensity and is squeezing type
Pain is persistent throughout the day
No history of radiation to the back
H/o of fever 10 days ago
No h/o of nausea and vomitings
There were no aggravating and relieving factors
Patient had a history of decreased urine output since 10 days and no urine output since yesterday and yesterday evening he had a history of fall due to giddiness and there is no LOC
H/O vomitings for 5 days, 5 to 6 episodes of vomitings and the content was food particles, immediately after eating anything but tolerating only fluidsfluids

No history of evening rise of temperature, cough, night sweats
No history suggestive of hemetemesis, melena, bleeding per rectum
No palpable mass per abdomen

Past history

Not a known case of DM, HTN, TB, epilepsy
No similar complaints in the past

Personal history
Diet- Mixed
Appetite- Decreased since 10 days
Bowel and bladder movements- Urine frequency is reduced since 3 days and patient has an history of constipation
Sleep- Adequate
Addictions-Chronic alcoholic since 15 years, consumes whisky daily(90 ml/day

Family history
No similar complaints in the family

General examination
Done after obtaining consent, in the presence of attendant with adequate exposure
Patient is conscious, coherent, cooperative and well oriented to time, place and person
Patient is well nourished and moderately built

Vitals
Temperature- Afebrile
Blood pressure- 80/60 mmHg
Pulse rate- 88 bp
Respiratory rate- 22 cpm

Local examination
Abdominal examination:

Inspection
Shape of the abdomen- Distended
Umbilicus- everted
Movements of abdominal wall- moves with respiration
Skin is smooth, shiny
No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites

Palpation
Inspectory findings are confirmed
Tenderness is present in whole of the abdomen
Guarding and rigidity present
Mild hepatosplenomegaly
Abdominal girth- 96.5 cms

Percussion
Resonant note is heard on the midline
Liver span- Not detectable

Auscultation
Bowel sounds are decreased

Investigations

Day 1 (14/10/22)

Hemogram
HB- 13.5
TC- 16400
Neutrophils- 84
Lymphocytes- 8
Eosinophils-2
Monocytes-6
Basophils-0
PCV-40.5
MCV-100.5
MCH-33.5
MCHC-33.3
RDW-CV-16
RDW-SD-56.5
RBC COUNT-4.03
PLT- 1.78

PROTHROMBIN TIME
Prothrombin time- 10-16 sec
INR- 1.85

APTT- 51 sec

BLOOD GROUPING AND TYPING
O POSITIVE 


RAPID HBsAG- NEGATIVE
RAPID HIV 1&2 - NEGATIVE
RAPID ANTI HCV ANTIBODIES- NEGATIVE

C-REACTIVE PROTEIN - 1:2 mg/dL

ECG
X ray 
Provisional diagnosis- AKI with MODS

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