29 year old male post renal transplant renal failure.

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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.

On 7th February a 29 year old male resident of west bengal computer technician by occupation came to General medicine opd for a regular checkup after live renal transplant in April 2021, reports ended up showing raised serum creatinine (3.8 mg/dle) and raised urea (85 mg/dl ). No complaints of decreased urine output, pedal edema, sob,facial puffiness, frothy urine, hematuria,. No history of fever,burning micturition.

Past history :

H/o previous admissions for haemodialysis for 2years. H/o two times intubation,extubation in view of pulmonary edema and hypertensive emergency and resistant hypertension two years ago. H/o loculated pleural effusion and ICD drainage 2years ago.

Family history: 

Personal history:patient does his daily activities,has a mixed diet with normal appetite.Sleep is adequate ,bowel and bladder movements are regular.Before transplant patient used to smoke 1 Cigarette per day and occasionally used to drink.

Treatment history:

After live renal transplant,at discharge patient was given immunosuppressants -prednisolone,tacrolimus ,mycophenolate mofetil.Few months later,he developed fungal infection ,then prednisolone was stopped and he was treated with anti fungal for 14 days

.

General examination: Patient is 

Conscious,coherent and cooperative well oriented to time,place and person. 

Moderately built and nourished.

Pallor: absent

Icterus : absent

Cyanosis: absent 

Clubbing : absent

Generalised Lymphadenopathy: absent 

Edema: absent 

VITALS

Temperature: Afebrile

Respiratory rate: 15cpm

Blood pressure : 140/100mm Hg 

Pulse rate : 72 bpm. 

Systemic examination:

CVS:

Inspection: apical beat seen, JVP seen.

Palpation: apical impulse felt at 5th intercoastalspace ,medial to midclavicular line 

Auscultation: S1,S2 present in all areas.No,murmurs are heard

RESPIRATORY system:

Inspection: normal

Palpation:bilateral normal chest expansion,tactile vocal Fremitus-resonant in all areas.

Percussion: resonant in all areas,liver dullness present.

Auscultation:normal vesicular breath sounds.

CNS: 

Higher mental tests,sensory(cranial nerves - intact) ,motor systems -normal

Abdominal examination: 

Inspection: surgical scar seen in right lumbar region and some part of right iliac region. Hyperpigmented areas seen.

Palpation: soft and non tender, hardness felt in right iliac region.

Percussion: no shifting dullness.

Auscultation: no bruits are heard.

PROVISIONAL DIAGNOSIS:Acute renal failure : secondary to tacrolimus toxicity 

Or

Secondary to chronic graft rejection.

INVESTIGATIONS: 

On 7/2/22

Blood urea:

Serum electrolytes:

Complete blood picture:

Urinary potassium:

On 25/2/22

ECG:

DOPPLER:

USG:

Urea and creatinine levels after admission:

BP chart:

Serum tacrolimus levels : 3.6 

Treatment : Methylprednisolone 500mg I.v. Twice daily I/v/o cellular rejection

Wysolone 10 mg 

Tacrolimus

MMF

Clonidine

Amlodipine

B complex