Saturday, January 11, 2025

36M With Renal Failure Telangana PaJR

 



11-01-2025

This is an Online E Log Book to discuss our patient's de-identified health data shared after taking his signed informed consent. Here we discuss our patient's problems through series of inputs from available global online community experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.

A 36 year old man developed loin pain and went to the doctor following which he was also found to have renal stones (CT abdomen attached) and was referred to Urology where the stones om the left kidney were tackled with Retrograde intrarenal surgery (RIRS)

He had some suspicious shadows in his chest X-ray (attached) and was treated with 6months of antitubercular therapy from the government DOTs program.

He also had glomerular injury and azotemia at the same time that perhaps got buried in the prominent attention garnered by the stones as well as his pulmonary tuberculosis!

The question here is what is the association between renal stones and glomerular injury?


Review 1: 

Recent studies have elucidated additional pathways whereby calcium oxalate crystals can cause acute injury, implicating innate immunity and intracellular inflammasome pathways. 

Unquote: https://pmc.ncbi.nlm.nih.gov/articles/PMC4096690/

Last admission EMR summary (discharged today):


Age/Gender : 36 Years/Male

Address :

Discharge Type: Relieved

Admission Date: 07/01/2025 04:25 PM

Diagnosis

Acute on chronic glomerular injury

AGN on CGN 

K/C/O HTN SINCE 1 YEAR

PAST H/O PTB 1 YEAR BAC

Case History and Clinical Findings 

C/O FACIAL PUFFINESS SINCE 10 DAYS

HOPI

PATIENT WAS APPARENTLY ASYMPTOMATIC 10 DAYS AGO THEN HE DEVELOPED FACIAL PUFFINESS SINCE 10 DAYS

NO H/O PEDAL EDEMA , DECREASED URINARY OUTPUT , SOB

KNOWN CASE OF CKD WITH HD IN MARCG 2024 AND THEN CHANGED TO CONSERVATIVE KNOWN CASE OF CAD SEVERE LV DYSFUNCTION MARCH 24

K/C/O HTN SINCE MARH 24 (I YEAR) N/K/C/O DM II , EPILEPSY , ASTHMA CVA , P/H/O PTB SINCE 1 YAER BACK GENERAL EXAMINATION :

PATIENT IS C/C/C

NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA BP: 130/80 MMHG

PR: 88 BPM

 RR: 20 CPM

SPO2: 99%

GRBS- 109 mg/dL SYSTEMIC EXAMINATION

CVS- SI, S2 HEARD, NO THRILLS, NO MURMURS RS- BAE +

ABDOMEN- SOFT, NON TENDER CNS- NFND

USG DONE ON 8/1/25

IMPRESSION - GRADE I RPD CHANGES IN B/L KIDNEYS WITH RENAL CORTICAL CYSTS LT RENAL RENAL CALCULI

Investigation

HB-11.4 TC-9000

N/L/E/M/B- 56/31/05/08/00 PCV-35.1

MCV-72.2

PLT COUNT-2.63

SMEAR - NORMOCYTIC NORMOCHROMIC

LIVER FUNCTION TEST (LFT) 07-01-2025 04:51: PM Total Bilurubin 0.50 mg/dl 1-0 mg/dl Direct Bilurubin 0.16 mg/dl 0.2-0.0 mg/dl (AST) 20 IU/L 35-0 IU/LSGPT(ALT) 17 IU/L 45-0

IU/LALKALINE PHOSPHATASE 343 IU/L 128-53 IU/LTOTAL PROTEINS 7.1 gm/dl 8.3-6.4

gm/dl ALBUMIN 4.00 gm/dl 5.2-3.5 gm/dl A/G RATIO 1.29

COMPLETE URINE EXAMINATION (CUE) 07-01-2025 05:28:PM COLOUR Pale yellow APPEARANCE Clear REACTION Acidic SP .GRAVITY 1.010ALBUMIN ++SUGAR Nil BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 5-6LLS 3-4RED BLOOD CELLS Nil CRYSTALS Nil  CASTS Nil AMORPHOUS DEPOSITS Absent OTHERS Nil

24 HR UPCR -2.47

24 HR URINE PROTEIN- 1485

24 HR URINE CREATININE -0.6

SERUM ELECTROLYTES (Na, K, C l) 07-01-2025 05:28:PMSODIUM 139 mmol/L 145-136

mmol/LPOTASSIUM 4.7 mmol/L 5.1-3.5 mmol/LCHLORIDE 104 mmol/L 98-107 mmol/L

BLOOD UREA 08-01-2025 05:31:PM 61 mg/dl 42-12 mg/dl SERUM CREATININE 08-01-2025

05:31:PM 3.3 mg/dl 1.3-0.9 mg/dl

 


SERUM ELECTROLYTES (Na, K, C l) 08-01-2025 05:31:PM SODIUM 141 mmol/L 145-136

mmol/LPOTASSIUM 5.3 mmol/L 5.1-3.5 mmol/LCHLORIDE 105 mmol/L 98-107 mmol/L

BLOOD UREA 09-01-2025 05:31:PM 61 mg/dl 42-12 mg/dlSERUM CREATININE 08-01-2025

05:31:PM 3.3 mg/dl 1.3-0.9 mg/dl

SERUM ELECTROLYTES (Na, K, C l) 08-01-2025 05:31:PM SODIUM 141 mmol/L 145-136

mmol/LPOTASSIUM 5.3 mmol/L 5.1-3.5 mmol/LCHLORIDE 105 mmol/L 98-107 mmol/L



BLOOD UREA 10-01-2025 05:31:PM 62 mg/dl 42-12 mg/dl SERUM CREATININE 08-01-2025

05:31:PM 3.2 mg/dl 1.3-0.9 mg/dl

SERUM ELECTROLYTES (Na, K, C l) 10-01-2025 05:31:PM SODIUM 141 mmol/L 145-136

mmol/LPOTASSIUM 5.2 mmol/L 5.1-3.5 mmol/LCHLORIDE 104mmol/L 98-107 mmol/L LIPID PROFILE -

TOTAL CHOLESTROL-148 MG/DL TRIGLYCERIDES -194 MG/DL HDL-43.4 MG/DL

LDL -38.8 MG/DL USG DONE ON 8/1/25

GEADE 1 RPD CHANGES IN B/L KIDNEY WITH RENAL CORTICAL CYSTS BACTERIAL CULTURE AND SENSITIVITY

URINE FOR CELLS - NO PUS CELLS SEEN

BLOOD FOR CELLS - NO GROWTH AFTER 48 HRS OF AEROBIC INTUBATION



LT RENAL CALCI

REVIEW USG WAS DONE 0N 11/1/25 RT KIDNET -8.4X3.2CM

LTKIDNEY 9X3.5 CM

SUBUNTIMETRIC B/L RENAL CORTICAL CYSTS

B/L GRADE 1 RPD CHANGES WITH SIMPLE RENAL CORTICAL CYSTS NEPHROLOGY OPINION

WAS TAKEN IN VIEW OF AKA ON CKD ON 11/1/25 AND ADVICED FOR CONSERVATIVE MANAGEMENT AND REVIEW AFTER 1 MONTH

Treatment Given (Enter only Generic Name)

FLUID RESTRICTION <1.5 L /DAY SALT RESTRICTION <2 G / DAY

 


TAB CIPROFLOXACIN 200 MG PO/BD TAB NODOSIS 1000 MG PO/BD

TAB CINOD -MT 10/50 MG PO/OD /8 AM TAB SHELCAL-CT PO/OD/2 PM

SYO URIKIND KM 10 ML 1 GLASS OF WATER PO/TID TAB LASIX 20 MG PO/OD

TAB PAN 40 MG PO/OD/7 AM

Advice at Discharge

FLUID RESTRICTION <1.5 L /DAY SALT RESTRICTION <2 G / DAY

TAB CIPROFLOXACIN 200 MG PO/BDX 3 DAYS TAB NODOSIS 1000 MG PO/B (TO BE CONTINUED)

TAB CINOD -MT 10/50 MG PO/OD /8 AM (TO BE CONTINUED) TAB SHELCAL-CT PO/OD/2 PM X 5 DAYS

SYO URIKIND KM 10 ML 1 GLASS OF WATER PO/TID (TO BE CONTINUED) TAB LASIX 20 MG PO/OD (TO BE CONTINUED)

TAB PAN 40 MG PO/OD/7 AM X 5 DAYS (TO BE CONTINUED)

Follow Up

REVIEW TO GM OPD AFTER 1 WEEK/SOS

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:  For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care, when and how to obtain urgent care have been explained to me in my own language

SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY

Discharge Date

Date:11/01/25

 Ward: MMW Unit: II



Second admission:

Admission Date: 07/05/2024 02:10 PM

Date of Operation

14/05/24

Treating unit 

Urology 

Diagnosis

LEFT RENAL CALCULUS WITH B/L DJ STENT INSITU PROCEDURE: LEFT RIRS + LEFT DJS UNDER GA

Case History and Clinical Findings

K/C/O CKD, PTB, CHF, HTN ON MEDICAL MANAGEMENT K/C/O B/L RENAL CALCULI, B/L DJ STENT ON 20/03/24 RIRS + R DJS ON 13/04/24

C/O DYSURIA AND VOMITINGS SINCE 3 DAYS

NO H/O LOIN PAIN , FEVER, HEMATURIA, TURBIDURIA, GRAVELURIA. CT KUB DONE ON 18/03/24

RIGHT KIDNEY- 8.4CM , MULTIPLE CALCULI LARGEST 8MM UPPER POLE (1000 HU) , 7MM MIDPOLE (500 HU) , 7MM LOWER POLE (700 HU), 5MM MIDPOLE (500 HU), 7MM LOWER POLE (800HU)

PULMONOLOGY OPINION ON 10/4/24

THEY ADVISED TO CONTINUE ATT AS ADVISED AND NEBULIZTION DUOLIN AND BUDECORT SOS

NEPHROLOGY OPINION ON 15/4/24

SUGERY CAN BE DONE WITH MODERATE RISK AND EXPLAINED TO PATIENT

Investigation

 


COMPLETE BLOOD PICTURE (CBP) 06-05-2024 03:42:PM HAEMOGLOBIN8.7 gm/dl TOTAL COUNT5400 cells/cummNEUTROPHILS45 %LYMPHOCYTES45 %EOSINOPHILS05

%MONOCYTES05 %BASOPHILS00 %PLATELET COUNT2.28SMEARmicrocytic hypochromic anemia

COMPLETE URINE EXAMINATION (CUE) 06-05-2024 03:42:PM COLOUR Pale yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN+++SUGAR Nil BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS4-5EPITHELIAL CELLS2-3RED BLOOD CELLS Nil CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS Absent OTHERS Nil

LIVER FUNCTION TEST (LFT) 07-05-2024 04:59:PM Total Bilurubin2.7 mg/dl Direct Bilurubin1.60 mg/dl SGOT(AST)60 IU/LSGPT(ALT)17 IU/LALKALINE PHOSPHATASE215 IU/LTOTAL PROTEINS7.1 gm/dlALBUMIN4.1 gm/dl A/G RATIO1.43BLOOD UREA07-05-2024 04:59:PM136

mg/dl

SERUM CREATININE07-05-2024 04:59:PM3.2 mg/dl

BLOOD UREA07-05-2024 04:59:PM136 mg/dl SERUM ELECTROLYTES (Na, K, C l) 07-05-2024 04:59:PM SODIUM135 mmol/LPOTASSIUM4.8 mmol/LCHLORIDE103 mmol/L

SEROLOGY - NEGATIVE

Treatment Given (Enter only Generic Name)

OPERTION NOTES: DONE ON 14/05/24

PROCEDURE: LEFT RIRS + LEFT DJ STENT UNDER GA

UNDER SAP UNDER GA PARTS CLEANED AND DRAPPED IN LITHOTOMY POSITION CYSTOSCOPY DONE, B/L DJ STENT REMOVED

LEFT URETERIC ORIFICE CANNULATED WITH 0.035 GUIDEWIRE AND ACCESS SHEATH 11F/9.5 PLACED

LEFT FLEXIBLE URETERORENOSCOPY DONE, MEASURING 5-7MM IN ALL POLES LEFT RIRS DOEN AND STENT PLACED

16FR FOLEYS PLACED POST OP INSTRUCTIONS:

1. NBM TILL FURTHER INSTRUCTIONS

2. VF RL/NS/DNS @ 50ML/HR

3. INJ. PIPTAZ 2.25G IV/BD

4. INJ. PCM 100ML IV/TID

5. INJ. PAN 40 MG IV/OD

6. INJ. ONDEM 4MG IV/SOS

7. INJ . TRAMADOL 50MG/IV/SOS

 


Advice at Discharge

INJ.PIPTAZ 2.25G IV BD FOR 5 DAYS

FOLLOWED BY TAB AUGMENTIN 625MG PO/BD X 1 WEEK TAB PAN 40MG PO/OD BBF X 1 WEEK

TAB PCM 650MG PO/TID X 5 DAYS TAB LIMCEE PO/OD X 10 DAYS TAB.MVT PO/OD X 10 DAYS

TAB.NODOSIS 500MG PO/BD X 1 MONTH CAP.BIO D3 PO/OD X 1 MONTH CONTINUE HTN MEDICATION CONTINUE ATT

CONTINUE CARDIAC MEDICATION

Follow Up

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.

REVIEW AFTER 1 WEEK TO UROLOGY OPD

When to Obtain Urgent Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:  For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language

SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY

Discharge Date Date:16/05/24 Ward: MSW Unit: UROLOGY



The chest X-ray that made him get started on antitubercular therapy by our pulmonology department on 

 March 2024.

16-01-2025

EMR SUMMARY



Age/Gender : 36 Years/Male
Address :
Discharge Type: Relieved
Admission Date: 18/03/2024 04:15 PM
Date of Operation
RGP+ B/L DJ STENT UNDER LA DONE ON 20/03/23
Name of Treating Faculty
PPM
Diagnosis
BILATERAL RENAL CALCULI WITH? RETROPERITONEAL FIBROSIS WITH? CKD WITH PTB ON ATT WITH? CHF
Case History and Clinical Findings
C/O LOSS OF APETITE, SCANTY URINATION, LOWER ABDOMINAL PAIN, GENERALISED WEAKNESS
NO H/O HEAMTURIA , GRAVELURIA K/C/O URINARY STONE
K/C/O HTN SINCE 2 MONTHS AND ON T. MET-XL 50 MG PO/OD AND T.TELMA 40MG PO/OD CT-KUB (PLAIN) :
1. RIGHT KIDNEY - 8.4 X 3.9 - MULTIPLE CALCULUS LARGESRT 8MM (900-1000 HU)
7MM MID (400-500HU)
7 MM LOWER POLE (450-500 HU)
2. LEFT KIDNEY 7.9 X 3.7 - 5MM UPPER POLE (650-700 HU)
5MM MID POLE (400-500 HU)
7MM LOWER POLE (700-800 HU)
URETER - SUBTLE SOFT TISSUE STANDINGS ANTERIOR TO AORTA AND IVC WITH MEDIAL DEVIATION OF MID PORTION OF BOTH URETERS
PANCREAS SHOWS ATROPIC PARENCHYMA AND NOMPD DILATION AND NO URETERS


USG DONE ON 18/3/24
 

RIGHT KIDNEY-8.2 X 3.3 CM E/O FEW CALCULI, LARGEST 4-5 MM IN MID POLE
LEFT KIDNEY- 8.2 X 3.2 CM CMD PARTIALLY LOST E/O FEW CALCULI LARGEST 3-4 MM IMPRESSION-
LEFT GRADE 1 RPD CHANGES LEFT RENAL CYST
BILATERAL RENAL CALCULI


NEPHROLOGY REFERRAL WAS DONE ON 18/3/24 I/V/O HIGH CREATININE LEVELS AND WAS ADVISED 2 SESSIONS OF HEMODIALYSIS WITH UF-500ML FOR 2 HOURS
GENERAL MEDICINE REFERRAL WAS DONE ON 20/3/24 I/V/O BP 180/70MMHG. ADVISE: LASIX 40MG IV/STAT
CONTINUE SAME ANTI HYPERTENSIVE TREATMENT


PULMONOLOGY REFERRRAL WAS DONE ON 20/3/24 I/V/O CHEST X RAY CHANGES ADVISE: CONTINUE ATT
ISONIAZID 5MG/KG OD RIFAMPICIN 10MG/KG OD
PYRIZINAMIDE 25MG/KGTHIRCE WEEKLY ETHAMBUTOL 15MG/KGTHIRCE WEEKLY TAB. BENADON 40MG PO/OD

Investigation
COMPLETE BLOOD PICTURE (CBP) 18-03-2024 HAEMOGLOBIN 11.3 gm/dl
TOTAL COUNT 9300 cells/cumm NEUTROPHILS 72 %
LYMPHOCYTES 19 %
EOSINOPHILS 03 %
MONOCYTES 06 %
BASOPHILS 00 %
PLATELET COUNT 3.24
SMEAR MICROCYTIC HYPOCHROMIC BT 2 MIN 00 SEC
CT 4 MIN 30 SEC
 



COMPLETE URINE EXAMINATION (CUE) 18-03-2024
COLOUR Pale yellow APPEARANCE Clear
REACTION Acidic SP.GRAVITY 1.010 ALBUMIN + SUGAR Nil
BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 2-4
EPITHELIAL CELLS 3-4 RED BLOOD CELLS Nil CRYSTALS Nil
CASTS Nil
AMORPHOUS DEPOSITS Absent OTHERS Nil

HBsAg-RAPID Negative
Anti HCV Antibodies - RAPID Non Reactive HIV 1/2 RAPID TEST NON REACTIVE

RFT 18/3/24
SODIUM 141 mmol/L
POTASSIUM 5.6 mmol/L
CHLORIDE 104 mmol/L
PHOSPHOROUS 8.5 MG/DL
UREA 284 MG/DL
CREATININE 9.2 MG/DL URIC ACID 8.6MMOL/L

FBS 101MG/DL
 

LIVER FUNCTION TEST (LFT) 18-03-2024
Total Bilurubin 0.86 mg/dl Direct Bilurubin 0.18 mg/dl SGOT(AST) 17 IU/L
SGPT(ALT) 13 IU/L
ALKALINE PHOSPHATASE 181 IU/L TOTAL PROTEINS 6.7gm/dl
ALBUMIN 3.97gm/dl A/G RATIO 1.45

Treatment Given(Enter only Generic Name)
OPERATIVE PROCEDURE :
UNDER SAP UNDER LA, PARTS CLEANED AND DRAPED IN LITHOTOMY POSITION ,WITH 19FR CYSTOSCOPY AND B/L RGP DONE.
NO NARROWING OF COLLECTING SYSTEM NOTED;NO FILLING DEFECTS NOTED BELOW PCS;PROMPT CLEARANCE OF CONTRAST NOTED AFTER 5 MINS FOLLOW UP FLOROSCOPY.
B/L 5F/26 DJ STENT PLACED 16FR FOLEYS PLACED

INJ MAGNEX FORTE 1.5G IV/BD TAB.PCM 650 PO/TID
TAB PAN 40 MG PO/OD BBF TAB.LIMCEE PO/OD TAB.NODOSIS 500 PO BD CAP. BIO D3 PO OD INJ.PCM 1G IV/SOS
CONTINUE HTN MEDICATION INJ TRAMADOL 1 AMPULE SLOW
Advice at Discharge
TAB.TAXIM 200 PO/BD X 1 WEEK TAB.PAN 40MG PO/OD BBF X 1 WEEK TAB.PCM 650 PO/BD X 5 DAYS TAB.LIMCEE PO/OD X 10 DAYS
 

TAB.NODOSIS 500 PO BD X 1 MONTH CAP. BIO D3 PO OD X 1 MONTH TAB.MET XL 50MG PO OD TAB.TELMA 40MG PO/OD
CONTINUE ATT
SYP.ALKASTONE B6 15ML IN 1/2 GLASS OF WATER PO/BD
Follow Up
R/A 1 WEEK TO UROLOGY OPD
When to Obtain Urgent Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: 08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Discharge Date Date: 21/03/24 Ward: MSW
Unit: UROLOGY



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