80 year old male with decreased urine output
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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 a diagnosis and treatment plan.
Case scenario:
A 80 year old male resident of nalgonda, farmer by occupation came with chief complaints of
-burning micturition since 10 days
-fever since 10 days
-decreased urine output since 4 days
-bilateral pedal edema since 4 days
-Blood in urine for 4 days
-altered sensorium since 4 days.
History of present illness:
Patient was apparently asymptomatic 10 days back. He then gradually developed burning micturition and high grade fever which was insidious in onset, intermittent, not associated with chills and rigors and relieved on medication.
He also had gradual decrease in urine output since 4 days, for which he consulted nearby rmp after 2 days and catheter was inserted. He also developed bilateral pedal edema which is of pitting type.
He had 2 episodes of vomitus which is non foul smelling, non bilious with contents being the food ingested. Relieved on medication.
He also had history of grade - 2 SOB for 4 days, which relieved on medication.
No h/o loose stools, abdominal pain, facial puffiness.
Past history:
Similar complaints of fever, vomitings associated with abdominal pain 8 years back and was treated accordingly.
5 years back, patient developed a blister in right ankle region which ruptured and an ulcer was formed. Treatment included ayurvedic medication. Ulcer healed after 2 years.
No HTN,DM,epilepsy,TB,asthma,CAD.
Personal history:
Diet: vegetarian
Appetite: decreased
Sleep:Adequate
Micturition: decreased with burning sensation.
Bowel movements: Regular
Allergies:No
Addictions:No
Family history:
No H/o Similar complaints in the family.
General examination:
Pt is drowsy but arousable and not oriented to person,time and place.
thin built.
No pallor
No icterus
No clubbing
No lymphadenopathy
B/L pedal edema
Patient has swelling in right inguinal region. On examination, it is reducible with no local rise of temperature and tenderness. Cough reflex cannot be elicited.
Vitals:
Temp : Afebrile
BP : 170/90 mm Hg
PR : 118 bpm
RR : 16 cpm
GRBS : 114 mg / dl
SpO2 : 98 % @ RA
Systemic examination:
CNS : E3 V5 M5
CVS : S1 & S2 heard, No murmurs
RS : BAE present, VBS heard
P/A : Soft , Nontender , BS +
Investigations:
X - ray:
USG:
ECG:
On 14/12/21
Fever chart:
ABG: (14/12/21)
on 15/12/21
On 14/12/21
Hemogram
14/12/21 16/12/21
Hb - 10.2 gm/dl. 9.1gm/dl
TLC - 21,400 cells/cumm 22,800 cells/ cumm
Neutrophils - 89% 85%
PCV - 25.4% 30%
RBC count - 3.18 3.57
Lymphocytes - 2% 4%
RFT:
14/12/21 15/12/21
Urea - 364mg/dl 215mg/dl
Creatinine - 9.1mg/dl 5.4mg/dl
Uric acid -11.7mg/dl 6.6mg/dl
Phosphorus - 6.6mg/dl 5.6mg/dl
Na -148mEq/L 151mEq/L
K - 6.8mEq/L 4.4mEq/L
Provisional diagnosis:
URAEMIC ENCEPHALOPATHY
POST RENAL AKI WITH UREMIC ENCEPHALOPATHY
PROSTATOMEGALY GRADE 1
B/L HYDROURETERONEPHROSIS
treatment :
INJ.PCM 1 GM /IV/SOS
INJ.PAN 40MG/IV/SOS
INJ.ZOFER 4MG/IV/TID
IVF NS@UO+30ML/HR
TAB.NICARDIA 10 MG/PO/STAT
BP/PR/TEMP MONITORING 4TH HOURLY
TAB. NODOSIN 500MG/PO/TID
INJ.PIPTAZ 4.5GM/IV/STAT
On 15/12/21
pt conscious, oriented to person,
Afebrile
pr 90 /min
Bp 140/80 mmhg
Spo2 99%
Cvs s1s2+
Rs b/l air entry +, b/l basal crepts +
Grbs 120 mg/dl
I/o 1200/1600
1 session of hemodialysis done on Tuesday morning.
On 16/12/21
Temp : Afebrile
BP : 100/60 mm Hg
PR : 86 bpm
RR : 22 cpm
GRBS : 100 mg / dl
SpO2 : 98 % @ RA
1 session of hemodialysis was done.
treatment :
INJ.PCM 1 GM /IV/SO
INJ.PAN 40MG/IV/SO
INJ.ZOFER 4MG/IV/TI
IVF NS@UO+30ML/H
TAB.NICARDIA 10 MG/PO/STA
BP/PR/TEMP MONITORING 4TH HOURL
TAB. NODOSIN 500MG/PO/TI
INJ.PIPTAZ 4.5GM/IV/STATDYTRDSS
On 17/12/21
No fever spikes
pt conscious, oriented to person,
Afebrile
pr 90 /min
Bp 90/70 mmhg
treatment
Inj piptaz 2.25 gm iv tid
Inj pan 40 mg iv od
Iv fluids 0.45 NS @ u.o.+30ml/hr
Tab pcm 650mg RT SOS
RT feeds free water,milk with protein powder 4th hrly
18/12/21
Fever chart:
ECG:
X-ray:
On 19/12/21
pt conscious,oriented to person , not to time and place
Temp- 99f
pr 104bpm
RR- 20cpm
Bp -90/70mmhg on inj noradrenaline @14ml/hr
Inj dobutamine @ 10ml/hr
Spo2- 98% with 4lit o2
Cvs s1s2+
Rs b/l air entry +, b/l basal crepts +
Per abdomen- soft, bs+
Grbs -106mg/dl
I/o-1500/300ml
3 session of hemodialysis done on 18/12 with UF of l litre
Treatment:
Inj meropenem 500mg iv bd
Inj pan 40 mg iv od
Iv fluids 0.45 NS @ u.o.+30ml/hr
Tab pcm 650mg RT SOS
RT feeds free water,milk with protein powder 4th hrly
On 20/12/21
pt conscious,oriented to person , not to time and place
Temp- 99f
pr 104bpm
RR- 20cpm
Bp -110/70mmhg on inj noradrenaline @6ml/hr
Inj dobutamine @ 10ml/hr
Spo2- 98% with 4lit o2
Cvs s1s2+
Rs b/l air entry +, b/l basal crepts +
Per abdomen- soft, bs+
Grbs -200mg/dl
I/o-1500/700ml
4session of hemodialysis done on 18/12 (uf-1lit), 19/12with UF of 2litre
Treatment:
Inj meropenem 500mg iv bd d3
Inj pan 40 mg iv od
Iv fluids 0.45 NS @ u.o.+30ml/hr
Tab pcm 650mg RT SOS
RT feeds free water,milk with protein powder 4th hrly
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