A 65 year old male with decreased urine output

 A 65 year old male resident of Bhongir who was farmer by occupation came with chief complaints of deceased urine output since 15 days and facial puffiness bilateral pedal edema since 15 days


HOPI 

Patient was apparently asymptomatic 3 years back.

Then a road accident occurred and got injured on his left thorax for which he took medication and diagnosed with hypertension

Then 1 yr back he had wound and it was not healing for which he went to aRMP doctor and was diagnosed with Diabetes mellitus for which he is on OHA.

He also had puffiness of face on and off since 1 year for which he visits the rmp and takes medication

Then now since 15  days he had decreased urine output (1 or 2 drops) and facial puffiness since 15 days  

He also had bilateral pedal edema (pitting) since 15 days and abdominal distension

5 days back he had an episode of vomiting and shortness of breath (grade 1) when he visited the AIIMS bhongir.

Then on 5 /08/2022 he came  our hospital

PERSONAL HISTORY

Diet mixed

Appetite Decreased

Bowel no stools since 15 days 

Bladder decreased urine output

Addictions occasionally alcohol

FAMILY HISTORY No significant family history

DRUG HISTORY No allergy to any kind of drugs


GENERAL EXAMINATION


 Patient was conscious coherent and cooperative


Moderately bulit and nourished


Pallor - present 


No Icterus , Clubbing, Cyanosis, Generalised lymphadenopathy


Bilateral pedal edema present pitting type


Vitals:


Temp:Febrile


Pulse rate: 90 bpm


Blood pressure:160/90


Respiratory rate: 20 cpm


GRBS:120mg/dl


SYSTEMIC EXAMINATION


RESPIRATORY SYSTEM EXAMINATION 


Inspection:


Symmetrical chest seen


No scars and sinuses 


Trachea central


Palpation:


Inspectory findings are confirmed


Percussion: 


Resonant note present in all lung areas


Ascultation:


Breath sounds heard. 


CENTRAL NERVOUS SYSTEM EXAMINATION 


HMF intact


Cranial nerves intact 


No focal neurological defecits 


PER ABDOMEN 


Inspection: 


No abdominal distension


No scars, sinuses, mass visible


Slit is everted


Palpation:


Inspectory findings are confirmed 


No local rise of temperature


Tenderness absent


Fluid thrill absent


Percussion:


Shifting dullness absent


Auscultation


: Normal bowel sounds heard


No bruit heard


CARDIOVASCULAR SYSTEM EXAMINATION 


Inspection : Bilaterally symmetrical chest present 


No scars, sinuses




Palpation:


Inspectory findings are confirmed


Apex beat normal


On Auscultation : 


S1 S2 heard


No murmurs or additional heart sounds


CENTRAL NERVOUS SYSTEM EXAMINATION 


Higher mental functions intact 


Cranial nerves intact 


No focal neurological defecits  

















INVESTIGATION 










 





 





DIAGNOSIS 

Acute kidney injury (Post renal)?

TREATMENT


On 5-8-2022:


Inj. LASIX 40mg I.v Stat.


On 6-8-2022:


Tab. NADOSIS 500mg P.o BD


Tab. SHELCAL P.o OD


Inj. 3%NaCl at 8ml/hr on flow.



Comments

Post a Comment

Popular posts from this blog

A 22 yr old female with generalized weakness and easy fatiguability since 2 months

Image
 A 22 yr old female who is a student came with complaints of generalized weakness and easy fatiguability since 2 months  History of Presenting illness Pt was apparently asymptomatic 5  years back then she started to have desire to eat non edible material and went to the hospital and was diagnosed with Anemia (Hb 4gm/dl) and 2 units of PRBC transfusion was done Now since 2 months she is complaining of easy fatiguability with generalized weakness  C/o SOB(grade ll-III) insidious in onset, gradually progressive to grade III,c/o exertional dyspnea  No c/o chest pain, palpitations, orthopnea,pnd  No c/o fever,loose stools, vomitings PAST HISTORY H/o similar complaints in the past H/o two PRBC transfusion N/k/c/o diabetes HTN TB Asthma Epilepsy thyroid disorders  PERSONAL HISTORY Diet  Mixed Appetite normal Sleep adequate Bowel and bladder  regular Addictions No  Daily routine  Pt wakes up around 7 am takes breakfast and goes for coaching...
Read more

65 year old male with cough since 2 months and fever since 15 days and chest pain since 1 day

Image
 This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs .This e-log book also reflects my patient centered  online learning portfolio and your valuable comments on comment box is welcome. I've 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 a diagnosis and treatment plan. A 65 year old male resident of chityal labourer by occupation came with chief complaints of fever, cough with sputum since 15 days and chest pain from  4pm of  23/06/2023 HISTORY OF PRE...
Read more

A 45 year old female patient presented with chief complaints of fever and shortness of breath

Image
 A 45 year old female patient resident of Chinthapally who is a agricultural labourer by occupation came with chief complaints of shortness of breath and fever since 15 days  HOPI  Patient was apparently asymptomatic 15 days back. Then she developed fever since 15 days associated with chills .She also has shortness of breath since 15 days. 15 days ago she had fever for which she went to the local hospital and got treated. After the treatment the fever subsided and she developed fever again for  which she went to the local hospital where she was diagnosed with thrombocytopenia.Then they came to Kims 3 days ago for the treatment of thrombocytopenia. No history of nausea vomiting. Past history :No history of Hypertension, tuberculosis, asthma. Personal history Diet:mixed  appetite : normal Bowel and bladder: regular Sleep : adequate Addictions:no addiction Family history:no relevant family history General examination: Patient is conscious, coherent and non-cooperat...
Read more