a38 yr old male pt c/o abdominal pain since 3 day h/o constipation since 2 day USG s/o left kidney small right sided hydronephrosis renal stone creat is 4.5 kindly suggest management and dx

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As.above..Ckd.+.Dm

Forced diuresis

Forced diuresis is never to be done with deranged kidney function test and hydronephrosis.
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Needs urgent drainage like dj stenting under antibiotic cover followed by urs

She is having solitary functioning right kidney with acute renal failure. Urine is showing ketosis. First manage the uncontrolled diabetes. Start good IV antibiotics. Then do right DJ stent.

Acute renal failure R. Side hydronephrosis with hydroureter with VUJ calculus UTI. Leucocytosis.

Thank you doctor
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It's indeed a complex and tricky case to manage There are few pressing issues which need to be tackled here and all of them are Domain of critical care specialist I will try to give highlights of them First let's jot down issues 1) Renal failure 2) Diabetic ketoacidosis 3) Sepsis 4) Electrolyte imbalance 5) Obstructive uropathy 1) This patient is young and has high creatinine, he is in obvious renal failure Pressing issue here is , does he require immediate dialysis Following are indication of immediate dialysis A) Hypervolemia - as seen by raised Central venous pressure in CVP line associated with bilateral chest crepitation suggestive of fluid overload, if it do not respond to diuretic therapy, then it's indication for immediate dialysis B) Acidosis - Severe acidosis as seen by Arterial blood gas, if it is not responding to treatment, it is an indication for dialysis C) Hyperkalemia - not responding to treatment with ECG changes, is an indication for dialysis D) Uremia - if it is set in, with its complication, it is an indication for dialysis In patient like this, Immediate CVP line to be inserted, bedside ultrasonography if available to be done to look for inferior vena cava distensibility - it is dynamic variable to look for 'Fluid responsiveness'. Per urethral Catheter to be inserted, hourly urine output is monitored, every effort is made to maintain urine output in normal range. Intravenous fluid to be given guided by CVP, IVC distensibility, pulse, blood pressure, urine output and crepitation in chest, this patient is in need of fluid but fluid overload is to be avoided, it is like walking on sharp sword 2) Diabetic ketoacidosis He is obviously in diabetic ketoacidosis, as urine Ketones are 3+, however urine sugars are absent, therefore his blood sugar may not be significantly raised He needs insulin infusion, for treatment of ketoacidosis with hyperglycemia, and once blood glucose is below 200 mg/dl, insulin infusion is changed to glucose insulin combination drip. It is continued till ketoacidosis is normalised. He must be dehydrated, he needs monitored fluid infusion, I prefer ringer lactate as fluid, however there are many who prefer normal saline as choice of fluid for correction of dehydration. 3) This patient is likely to be on sepsis, antibiotics need to cover E. Coli, and preferably ESBL STRAINS to be covered. Piperacillin and Tazobactum can be preferred choice Dose to be adjusted to creatinine clearance eGFR 4) Electrolyte imbalance is to be expected and corrected expeditiously 5) Once patient is stabilized, right URS with DJ Stenting or if it is high risk, pain DJ STENTING to be done to treat Obstructive uropathy I may not have touched many other important issues for want of time and space But enough to mention, he is very critical and need to be managed in ICU

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Acute renal failure Rt side hydronephrosis with hydroureter with VUJ cal UTI Leucocytosis Urgent UROLOGIST & NEPHROLOGIST opinion ADV BLOOD SUGAR FASTING PP, HBA1C, LFT RFT ELECTROLYTE, HIV, RENAL COLOUR DOPPLER BLOOD & URINE CULTURE X-RAY CHEST ECG 2D ECHO RT URS WITH DJ STENTING CORRELATED CLINICALLY FOR FURTHER MANAGEMENT

Thank you doctor
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