Case presentation

27th June, 2022

Presenter: Dr. Amninder Kaur, Senior Resident

Moderator: Dr. Sandeep Saini, Assistant professor dept of Nephrology
Dr. Dipesh K Dhoot, Assistant professor dept of Nephrology
AIIMS, Rishikesh
 Patient details

• 23 year male

• Resident of Haldwani

• Private employee
• History given by patient and mother
• Date of admission in hospital: 18/6/2022
 Chief complaints

• Decrease appetite – 10 days

• Vomiting - 8 days

• Pain abdomen - 5 days

• Decrease urine output – 5 days

• Abnormal body movements –

• Fever -
 History of present illness
• Decrease appetite – 10 days

• Earlier used to take 5-6 chapatti per meals

• Decreased to 2 chapatti per meals
 History of present illness
• Vomiting – 8 days
• 3 times per day
• Contain water content
• No blood
• Projectile, associated with nausea
• Amount 100 ml
• Relieved with medication after 2 days, frequency decreased to
once per day
• Not associated with headache, vomiting, altered sensorium,
dizziness
• Not associated with diarrhea, constipation
 History of present illness
• Pain abdomen – 5 days

• Sudden onset, diffuse in location, moderate intensity (7/10)

• Radiating to back, Intermittent
• No relation with food intake
• Relieved with medications after 30 mins, again reappeared
after 6 to 7 hours, now relieved sine ------ days
• it was not associated with diarrhea, constipation
 History of present illness
• Decrease urine output 5 days
• Earlier used to pass 7 to 8 times
• Frequency decreased to 2 times per days
• Amount also decreased  around 50 ml every time
• Urine output improved after 5 days, frequency increased to 4
times per days, amount increased to 100-150 ml every time,
at present he is passing urine around 2 litres. (when imroved)
• No history of hematuria, nocturia, froth in urine, cola colored
urine
• No history of

• fever, burning micturation, increase frequency of micturation

• Cough, shortness of breath, blood in sputum

• Yellowish discoloration of eyes, urine

• Dizziness, palpitations

• Alternative medications

• Pedal edema

• Joint pain, rash, oral ulcers, photosenstivity

• Blood in stools, black colored stools

• Blood transfusion
• Patient got admitted on day 5th (around 13/6)
• Not told to have high/low blood pressure
• 2 bottles of fluids were given
• Not aware about any antibiotics
• Told to have low hemoglobin but no blood transfused
• Told to have deranged renal function, not aware about Creatinine
level, no dialysis given
• Urine routine was done but he was not told regarding proteinuria,
RBC in urine, not aware regarding ultrasound
• Remain admitted for 2 days
• Urine output
• Referred to higher centre on (date 15/6)

• He was told to have high blood pressure (160 mmHg systolic)

• Blood investigations were done
• Told to have deranged renal function, no HD given
• Remained admitted for 1 day
• At that time his urine output was

• Referred to Nephrologist, came to AIIMS Rishikesh on

 Treatment history
• Patient came to AIIMS on 18/06/2022
• His blood pressure was high at admission
• Blood investigation was done, told regarding deranged renal
function
• Urine routine was done not told to have proteinurea and RBC
• 24 hour urine collection was done (volume was aprox 2.8 litre
as per patient, not aware about report)
• Urine output since admission
• USG was normal as per patient, not informed regarding small
size kidneys, renal stone
 Treatment history
• Dialysis initiated via dialysis catheter inserted right side of neck
in view of uremic symptoms

• 3 session of dialysis given daily, of increasing duration

• Weight loss after dialysis

• No blood transfused during HD

• Patient had abnormal body movements after 1 hour 30 mins of

first HD
 Treatment history
• Generalized tonic clonic, uprolling of eye balls present, no
froth from angle of mouth, no urinary or faecal incontinence,

• Transient loss of consciousness regain after 3 minutes and no

post ictal confusion was present

• Not associated with headache vomiting, no history of high

blood pressure at that time.

• Similar episode of seizure occurred after 2 hour, he was given

some injection
 Treatment history
• No episode of seizure after 2nd HD session
• CT head
• Fever since 3 days
• Documented around 100 F
• Occurred after dialysis
• Associated with chills
• Relieved with medication
• Not associated with rash, joint pain, cough , shortness of
breath, burning micturation, headache, altered sensorium,
diarrhea
• Now afebrile since
 Past history
• No h/o-

Diabetes
Hypertension
Tuberculosis
Drug history
 Drug allergy

• Not known
 Family history
• No history of
• Hypertension
• Diabetes
• similar complaints/ renal dysfunction in family
 Personal history

• Bowel habit is normal

• Urine output is normal

• Alcoholic 
• Smoker
 Dietary history

• Mixed diet
Summary
 Syndromic diagnosis
• Acute kidney injury KDIGO Stage 3,
Nonoligouric
• Etiology 
• Seizure (?DDS)
• ?CRBSI
• Acute on CKD
 General Physical Examination

• Conscious, well oriented

• Body weight- 68 kg
• Height- 168cm
• BMI- 24.2 kg/m2
 General Physical Examination
• Vitals
• PR- 80/min, regular, normal in volume and
character, no radioradial or radiofemoral delay
• BP- 130/80mmHg in right UL in supine position
– 130/70 in left UL in supine position
– 140/80 in right lower limb in supine position
• RR- 20/min, abdominothoracic
• Afebrile on touch
 General Physical Examination
• Pallor present
• No icterus, cyanosis, clubbing,
lymphadenopathy, pedal edema
• No facial puffiness
• No rash in extremities, no malar rash
• No white nail
• No half and half nail
• No generalized skin pigmentation
 General Physical Examination
• Double lumen temporary HD catheter is in situ
in right IJV with intact dressing
• JVP- not seen because of presence of HD
catheter
 Systemic examination
Abdomen examination:
• Inspection- Flat, umbilicus central in position
– Flanks free
– No scar, hernia

• Palpation
– Soft, non tender, normal temprature
– No hepatosplenomegaly
– No renal angle tenderness
– On bimanual palpation kidneys are not palpable
 Systemic examination
Abdomen examination:

• Percussion
– No shifting dullness
– No fluid thrill

• Auscultation
– Normal bowel sounds
– No renal bruit
 Systemic examination
Cardiovascular examination:
• Inspection
– Shape normal, no scar mark, No visible pulsations seen
– Apex in 5th ICS on mid clavicular line

• Palpation
– Apex- 5th ICS on mid clavicular line
– No thrill palpable
– No parasternal heave
 Systemic examination
Cardiovascular examination:

• Auscultation:
– S1,S2 heard in apex
– No S3 in mitral area
– No murmur present
– No pericardial rub
 Systemic examination
• Respiratory system examination:

• Inspection:
o Normal shape of chest
o Moving symmetrically with respiration
o No scar or sinus
o No venous prominence

• Palpation
– Temp – normal, no tenderness
– Apex- 5th ICS on mid clavicular line
 Systemic examination
• Respiratory system examination:
• Percussion:
o Normal resonance
o Liver dullness is present in right 6th IC, cardiac in left 4th IC space

• Auscultation:
o B/L normal vesicular breath sound is heard
o No crepitations
o No ronchi
o No bronchial breath sound
 Systemic examination

• Nervous system examination:

– Higher mental function normal

– Motor, sensory examination normal
– Reflexes are normal
 Urine dipstick:

• Protein 2+
• Blood 2+
• Leukocyte- nil