45 years old male with anuria

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I have 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 diagnosis and treatment plan

M Kalpana 

Roll no -92

Case history-

A 45 years old male came with 

-c/o anuria since 1 day 

-Right lowerlimb swelling since 3 days

 -Episodes of fever with chills (intermittent) since 2days

History of presenting illness-

Patient was apparently asymptomatic 3 days back then he developed swelling over Right lower limb with blisters over it ,Insidious in onset, gradually progressive and presently upto Right mid thigh region. Associated with dull aching pain.

Patient went to a local hospital and fasciotomy was done under LA -Saturday (I.e 18/3/23)

H/o Fever , high grade, intermittent since 3 days associated with chills . Relieved on medication. 

No sob

H/o anuria since 1 day.

PAST HISTORY

K/c/o Type 2 DM since 5 years and on medications 

    • TAB GLIMEPIRIDE 1MG 

    • TAB METFORMIN 500MG 

K/c/o HTN since past 3 years and on medications

  •TAB OLMESARTAN 20MG

  •TAB CILNIDIPINE 40MG

N/K/C/0 CAD, EPILEPSY, ASTHMA, TB , CVA ,THYROID DISORDERS 

PERSONAL HISTORY -

APPETITE NORMAL 

DIET-MIXED 

BOWEL-REGULAR 

BLADDER- ANURIA SINCE 1DAY 

H/o alcohol intake since 18 years

General examination-

No pallor ,icterus, cyanosis, clubbing , lymphadenopathy 

Edema present -pitting type

Vitals-

Bp -160/90 mm hg

PR-94bpm

Temp-96.4 f

RR- 24cpm

SPO2- 95%on RA

Grbs - 97mg/dl

Systemic examination-

CVS-s1, s2 heard , no murmurs

RS-BAE , decreased breath sounds on right IAA, ISA 

P/A- soft , nontender 

Diagnosis 

Septic shock 2° to Right lower limb cellulitis 

AKI on CKD stage 5  ? diabetic nephropathy

Hyponatremia  (?dilutional) ——?pseudo with 

Hypokalemia with anemia of chronic disease

?OHA induced hypoglycemia with DM -2 since 5years and HTN since 3 years

19/3/23

22/3/23

23/3/23

27/3/23

19/3/23

2d echo -

20/3/23

20/3/23

22/3/23

23/3/23

24/3/23

25/3/23

20/3/23 reports-

Investigation chart-

ABG 

Treatment-

 -IVFs -NS at 75ml/hr 

-inj piptaz 4.5 gm /IV /stat 

-inj clindamycin 600 mg / IV /tid

-inj pan 40 mg /IV /OD

-inj hai s/c tid 

-Tab nicardia 10mg /po/sos

-limb elevation 

-Bp monitoring 2nd hourly and GRBS

Surgery referral I/v/o diabetic foot 

Daily dressing done by surgery-

Ophthal referral I/v/o diabetic retinopathy-

SOAP NOTES-

ICU BED -2

S

Fever spike present at 8pm-100.4 F

O 

Pt is c/c/c 

Afebrile on touch

Bp -140/90 mm hg

PR-104/min

Temp-98.8 F

RR- 28 cpm

SPO2- 88% on 10lts of 02

           92% on fio2 -100%

Grbs - 313 mg/dl

Input- 1010 ml

Output- 130 ml

Systemic examination-

CVS-s1, s2 heard , no murmurs

RS-BAE , inspiratory crepts present in left IAA

P/A- soft , nontender

CNS- NAD

Diagnosis 

Aki on ckd stage 5 ? diabetic nephropathy with 

Sepsis 2° to Right lower limb cellulitis  with ? ARDS with 

Hyponatremia (?dilutional) -?pseudo (resolved)

Hypokalemia with anemia of chronic  disease

?OHA induced hypoglycemia (resolved)

With flash pulmonary edema

With type II diabetes since 5 years and HTN since 3years

With 3 sessions of hemodialysis

P

-Head end elevation upto 30 degrees 

-Intermittent cpap support

-Inj meropenem 500 mg IV/BD

-Inj metrogyl 500mg IV /TID

-Inj pan 40 mg IV /OD

-Inj lasix 40mg IV /TID

-Tab nicardia 70mg po/TID

-Syp potklor  70 ml po /TID

-Limb elevation and daily dressing of bilateral lower limb 

-GRBS monitoring 6th belt

-Strict I/O charting

-BP/temp/PR/RT monitoring

24/3/23

Unit-2

 ICU BED 2

S

No Fever spike

Stools not passed

O 

Pt is c/c/c 

Temp - 98.4F

Bp -140/100 mm hg

PR-104/min

RR- 22 cpm

SPO2- 87% on 6 lts of 02

           92% on fio2 -90%

Grbs - 212 mg/dl

Input- 900 ml

Output- 200 ml

Systemic examination-

CVS-s1, s2 heard , no murmurs

RS-BAE , bilateral wheeze present in ISA, axillary and IAA

P/A- soft , nontender

CNS- NAD

Diagnosis 

Aki on ckd (stage -5) ? diabetic nephropathy with 

Sepsis 2° to Right lower limb cellulitis  with ? ARDS with 

Hyponatremia (?dilutional) -?pseudo (resolved)

Hypokalemia with anemia of chronic  disease

?OHA induced hypoglycemia (resolved)

With flash pulmonary edema

With type II diabetes since 5 years and HTN since 3years

With 4 sessions of hemodialysis

P

-Head end elevation upto 30 degrees 

-Intermittent cpap support

-Inj meropenem 500 mg IV/BD (day 6 )

-Inj metrogyl 500mg IV /TID. ( Day 2 )

-inj pan 40 mg IV /OD

-Inj lasix 40mg IV /TID

-Tab nicardia 10mg po/TID

-Syp potklor   70 ml po /TID

-nebulisation with ipravent and budecort 8hrly

-Limb elevation and daily dressing of b/L limbs

- GRBS monitering 6 th hrly

- strict I/O charting

-Bp temp pr rr monitoring

Fever charting—

25/3/23

S

No Fever spike

Stools passed

O 

Pt is c/c/c 

Temp -98. 8F

Bp - 150/90 mm hg

PR-104/min

RR- 28 cpm

SPO2-  98 % on  NIV         

Grbs - 150 mg/dl

Input- 500 ml

Output- 200 ml

Systemic examination-

CVS-s1, s2 heard , no murmurs

RS-BAE , bilateral wheeze present in ISA, axillary and IAA

P/A- soft , nontender

CNS- NAD

Diagnosis 

Aki on ckd stage  2° to  diabetic nephropathy with 

Sepsis 2° to Right lower limb cellulitis  with ? ARDS with 

Hyponatremia (?dilutional) -?pseudo (resolved)

Hypokalemia with anemia of chronic  disease

?OHA induced hypoglycemia (resolved)

With flash pulmonary edema

With type II diabetes since 5 years and HTN since 3years

With 4 sessions of hemodialysis

P

-Head end elevation upto 45 degrees 

-Intermittent cpap support and O2 supplementation

-Inj meropenem 500 mg IV/BD day 6

-Inj metrogyl 500mg IV /TID. Day 3

-inj pan 40 mg IV/OD

-Inj lasix 40mg IV /TID

-Tab nicardia 10mg po/TID

-Nebulization, ipravent, budecot 8th hrly

-Syp potklor  10 ml po /TID

-Limb elevation and daily dressing

- GRBS monitering 6 th hrly

- strict I/O charting

-Bp ,temp, PR, RR monitoring 2nd hrly

27/3/23

Unit-2

Date of admission-19/3/23

S

No Fever spikes

Stool passed today 

O 

Pt is c/c/c 

Afebrile on touch

Bp -160/80 mm hg

PR-92/min

Temp-98.6 F

RR- 24 cpm

SPO2- 98 %on 4 ltrs of 02

GRBS-174 mg/dl

Input-  900 ml

Output- 20 ml

Systemic examination-

CVS-s1, s2 heard , no murmurs

RS-BAE , bilateral basal crepts present 

P/A- soft , nontender

CNS- NAD

Diagnosis -

Aki on ckd stage 5 ? diabetic nephropathy with 

Sepsis 2° to Right lower limb necrotising fasciitis (tissue c/s -acinetobacter-s/e colistin)with

Hyponatremia (?dilutional) -pseudo (resolved)

Hypokalemia with anemia of chronic  disease

?OHA induced hypoglycemia (resolved) with ARDS 

With ?flash pulmonary edema

With type II diabetes since 5 years and HTN since 3years

With 5 sessions of  hemodialysis with septic shock 

P

-Head end elevation upto 45 degrees

-O2 inhalation with intermittent CPAP support

-Inj lasix 40 mg/IV /TID 

-tab nicardia 10 mg /po /TID

-Inj pan 40 mg IV /OD /BBF

-Inj lasix 40mg IV /TID

-Syp potklor  70 ml po /TID in glass of water

-Tab dolo 650 mg PO/SOS

-Inj HAI s/c TID as per GRBS

-Inj noradrenaline 5ml /hr /IV increase /decrease according to MAP > 65mm hg 

-Limb elevation and daily dressing of bilateral lower limb 

-GRBS monitoring 7 point profile 

-Strict I/O charting

-BP/temp/PR/RT monitoring

30/3/23

Unit-2

Date of admission-19/3/23

S

2 fever spikes present at 4 pm and 7 am 

Stool passed today 

O 

Pt is c/c/c 

Afebrile on touch

Bp -140/90 mm hg

PR-102/min

Temp-98.8 F

RR- 24 cpm

SPO2- 97%on 4 ltrs of 02

GRBS-156 mg/dl

Input-  2500 ml

Output- 750 ml

Systemic examination-

CVS-s1, s2 heard , no murmurs

RS-BAE , bilateral crepts in IAA

Wheeze present 

P/A- soft , nontender

CNS- NAD

Hb 6.5

TC 27700

N 85

L 10

Pcv 20.3

RBC 23.7

Plt 3.11

pH 7.47

Pco2 23.4

Hco3 17.2

Po2 78.4

Blood urea 103

Creat 5.9

Calcium 7.9

Phosphorus 5.1

A

Diagnosis -

Aki on ckd stage 5 ? diabetic nephropathy with 

Sepsis 2° to Right lower limb necrotising fasciitis (tissue c/s -acinetobacter-s/e colistin)with

Hyponatremia (?dilutional) -pseudo (resolved)

Hypokalemia with anemia of chronic  disease

?OHA induced hypoglycemia (resolved) with ARDS 

With ?flash pulmonary edema

With type II diabetes since 5 years and HTN since 3years

With 6 sessions of  hemodialysis with septic shock 

P

-Head end elevation upto 45 degrees

-O2 inhalation with intermittent CPAP support

-Inj lasix 40 mg/IV /TID 

Inj Tramadol 100mg in 100ml NS IV/bd 

-tab nicardia 10 mg /po /TID

-Inj pan 40 mg IV /OD /BBF

-Syp potklor  70 ml po /TID in glass of water

-Tab dolo 650 mg PO/SOS

-Inj HAI s/c TID as per GRBS

Neb with iptavent and budecort 8th hourly 

-Limb elevation and daily dressing of bilateral lower limb 

-GRBS monitoring 7 point profile 

-Strict I/O charting

-BP/temp/PR/RT monitoring

1/4/23

Unit-2

Date of admission-19/3/23

S

1 fever spikes present at 3 am 

Stool passed today 

O 

Pt is c/c/c 

Afebrile on touch

Bp -150/90 mm hg

PR-92/min

Temp-98.4 F

RR- 24 cpm

SPO2- 99 on room air 

GRBS-229mg/dl

Input-  700 ml

Output- 200 ml

Systemic examination-

CVS-s1, s2 heard , no murmurs

RS-BAE , NVBS present 

P/A- soft , nontender

CNS- NAD

Hb 9.3

TC 15700

N 88

L 6

Pcv 29.2

RBC 3.33

Plt 2.33

Aptt 32

Bt 2min

Ct 4 min

Pt 16

Inr 1.11

Tb 2.45

Db 0.49

Alp 428

Blood urea 43

Creat 3.1

Uric acid 2.6

Na 138

K 3.7

Cl 98

A

Diagnosis -

Aki on ckd stage 5 ? diabetic nephropathy with 

Sepsis 2° to Right lower limb necrotising fasciitis (tissue c/s -acinetobacter-s/e colistin)with

Hyponatremia (?dilutional) -pseudo (resolved)

Hypokalemia with anemia of chronic  disease

?OHA induced hypoglycemia (resolved) with ARDS 

With ?flash pulmonary edema

With type II diabetes since 5 years and HTN since 3years

With 8 sessions of  hemodialysis and 3 units PRBC transfusion with septic shock 

P

-Head end elevation upto 45 degrees

-O2 inhalation with intermittent CPAP support

-Inj lasix 40 mg/IV /TID 

Inj Tramadol 100mg in 100ml NS IV/bd 

-tab nicardia 10 mg /po /TID

-Inj pan 40 mg IV /OD /BBF

-Syp potklor  70 ml po /TID in glass of water

-Tab dolo 650 mg PO/SOS

-Inj HAI s/c TID as per GRBS

Neb with iptavent and budecort 8th hourly 

-Limb elevation and daily dressing of bilateral lower limb 

-GRBS monitoring 7 point profile 

-Strict I/O charting

-BP/temp/PR/RT monitoring

2/4/23

Unit-2

Bed 2 

Date of admission-19/3/23

S

1 fever spikes present at 3 am 

Cough with sputum since yesterday evening 

O 

Pt is c/c/c 

Afebrile on touch

Bp -150/90 mm hg

PR-88/min

Temp-98.4 F

RR- 20cpm

FiO2- 98 on room air 

GRBS-107mg/dl

Input-  1250 ml

Output- 300 ml

Systemic examination-

CVS-s1, s2 heard , no murmurs

RS-BAE , NVBS present 

P/A- soft , nontender

CNS- NAD

Hb 8.2

TC 11700

N 74

L 14

Pcv 24.6

RBC 2.87

Plt 2.58

Aptt 32

Bt 2min

Ct 4 min

Pt 16

Inr 1.11

Tb 2.45

Db 0.49

Alp 428

Blood urea 63

Creat 4.2

Uric acid 4.4

Na 139

K 3.5

Cl 101

A

Diagnosis -

Aki on ckd stage 5 ? diabetic nephropathy with 

Sepsis 2° to Right lower limb necrotising fasciitis (tissue c/s -acinetobacter-s/e colistin)with

Hyponatremia (?dilutional) -pseudo (resolved)

Hypokalemia with anemia of chronic  disease

?OHA induced hypoglycemia (resolved) with ARDS 

With ?flash pulmonary edema

With type II diabetes since 5 years and HTN since 3years

With 8 sessions of  hemodialysis and 3 units PRBC transfusion with septic shock 

P

-Head end elevation upto 45 degrees

-O2 inhalation with intermittent CPAP support

Inj pan 40mg Iv / od 

-Inj lasix 40 mg/IV /TID 

Inj Tramadol 100mg in 100ml NS/Iv /bd

Tab nicardia 10 mg po / tid 

Tab dolo 650 mg po / tid 

Inj hai s/c tid according to grbs 

Grbs 7 point profile monitoring

3/4/23

Unit-2

Bed 2 

Date of admission-19/3/23

S

 fever spikes present at 12 am and 2 am 

O 

Pt is c/c/c 

Temp 100.1F°

Bp-140/80 mmHg

Pr-111bpm

Rr-24cpm

Spo2-99% on RA

 GRBS-148 mg/dL

Input-  1250 ml

Output- 300 ml

Systemic examination-

CVS-s1, s2 heard , no murmurs

RS-BAE , NVBS present 

P/A- soft , nontender

CNS- NAD

A

Diagnosis -

Aki on ckd stage 5 ? 2° to diabetic nephropathy with 

Sepsis with septic shock 2° to Right lower limb necrotising fasciitis (tissue c/s -acinetobacter-s/e colistin)with

Hyponatremia (?dilutional) -pseudo (resolved)

Hypokalemia with anemia of chronic  disease

?OHA induced hypoglycemia (resolved) with ARDS 

With ?flash pulmonary edema

With type II diabetes since 5 years and HTN since 3years

With 9 sessions of  hemodialysis and 3 units PRBC transfusion with septic shock 

P

-Head end elevation upto 45 degrees

-O2 inhalation with intermittent CPAP support

Inj pan 40mg Iv / od 

-Inj lasix 40 mg/IV /TID 

Inj Tramadol 100mg in 100ml NS/Iv /bd

Tab nicardia 10 mg po / tid 

Tab dolo 650 mg po / tid 

Inj hai s/c tid according to grbs 

Grbs 7 point profile monitoring