60 yr old male pt with B/L Hydronephrosis

 

A 60 year old male patient, agricultural labourer by occupation,

married, living with his wife , had one son

 ( who passed away at the age of 5 reason ?unknown) and has one daughter ( married, lives in Nalgonda) resident of mutthayigudem came to 

KIMS , Narketpally on 13/01/22 with c/o pain abdomen, decreased urine output, fever, nausea and vomiting since 20 days.

The patient was apparently asymptomatic 1 year ago, used to go to work everyday, when he developed b/l pedal edema ( upto ankle), decreased urine output, burning micturition, flank pain, dragging type, radiating towards abdomen but the patient did not get himself checked due to financial issues. 3 months ago they went to a hospital in Nalgonda with the same complaints where he was diagnosed with b/l renal calculi and was given medication after which his complaints resolved. 

2 months later he again again had c/o 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 chief C/O fever with chills and Rigors and generalised body pains for 3 days

USG report showed 

1. Right gross pyonephrosis 
2. Left gross hydronephrosis
3. Liver hemangioma

For which he was given medication and referred to urologist.

On 08/01/22 one of his relatives took him to a hospital in kammam 

where his 

Sr. Creat was 11.2 mg/dl and USG showed 

1. Grossly hydronephrotic Rt kidney with almost no cortex, enlarged renal pelvis, due to proximal ureteric calculus of 2.1 cm, showing 1632 HU 
2. Severe hydronephrosis of Lt kidney seen with thinking of cortex, dilation of ureter due to ureteric calculus of 2.6 cm, showing 1700 HU at iliac vessels.
3. Prostate enlarged 

On 12/01/22 they again went to another hospital on Nalgonda with c/o b/l loin pain, fever, vomitings, dysuria, decreased stream.

No H/o hematuria, shortness of breath, palpitations.

On CT abd:

1. Gross HDN of Rt kidney with proximal ureteric calculus of 2 cm.
2. Lt severe HDN with 2.6 cm mid ureteric calculus.

Plan: B/l percutaneous nephrostomy

Pt was counselled about requirement of haemodialysis and was referred to KIMS,

Narketpally 

Pt underwent one session of dialysis on 15/01/22

Pt is not a k/c/o HTN, DM, TB, Asthma, epilepsy.

Vitals on admission 

Temp- afebrile 

BP- 140/80 mm hg

PR- 100 bpm

RR- 22 bpm

Spo2- 98 % @ RA

GRBS- 116 mg/dl 

CVS- S1 S2 + No murmurs 

RS- BAE+ No added sounds 

P/A- soft, tenderness + diffuse , BS+

CNS- NAD

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 13/01/22

ECG ON 14/01/22

Chest X Ray

USG FINDINGS:

Rt proximal ureteric calculus causing gross hydronephrosis 

Lt distal ureter calculus causing proximal moderate hydronephrosis 

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 @ 10 mins 

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

Inj Sodium bicarb 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

Urology referal:

On 19/01/22

Day 6

S:

C/o fever with chills 

1 g neomol given 

Last session of haemodialysis on 15/01/22

O:

Temp-101.6F

BP- 110/90 mmhg

PR- 96 bpm

RR- 19 cpm

Sr. Creat-10.6

Urea-217

Na-135

K-5.1

Cl-94

A:

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

P:

IV fluids

Inj lasix 20 mg IV/BD

Inj Pan 40 mg IV/OD

Inj Zofer 4 mg IV/TID

Inj Thiamine 1 amp in 150 ml NS IV/OD 

Tab PCM 650 mg PO/SOS

Tab. Nodosis 500 mg PO/BD

Tab Orofer XT PO/OD

Salt restriction < 2.4 g/ day

LEFT PERCUTANEOUS NEPHROSTOMY UNDER LOCAL ANAESTHESIA DONE ON 19/01/22

X-RAY KUB

USG ABDOMEN 

Findings:

1. Grade II RPD changes in Lt kidney

2. Grossly dilated PCS of Rt kidney compressing the renal parenchyma.

 

20/1/21

Day 7 

S : SOB reduced 

Fever spikes present 104 F

Cough reduced

One session of haemodialysis done on 19/1/22

O/E pt c/c/c

Febrile 102.6 F

BP - 100/70

PR - 88bpm

CVS - S1S2+

RS - BAE+

P/A - soft, non tender

One session dailysis done on 14/01/22

Creatinine : 16.3 --> 9.5

Urea : 278 --> 162 --> 217

A: 

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

P : To watch for reduction of urea and creatinine.