1701006086 CASE PRESENTATION
LONG CASE:
CHIEF COMPLAINTS:
80 year old male patient came with chief complaints of
Decreased urine output since 2 days
Pain in the abdomen since 2 days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 10 years back then he developed fever which was continuous ,not relieved on medication and associated with chills and rigors and decreased urine output for which he went to a hospital and was diagnosed with acute renal failure and had three sessions of dialysis.He was also diagnosed with hypertension and is on regular medication(Telmikind) since then.
He had recurrent episodes of burning micturition with increased frequency and dysuria for which he took symptomatic treatment.
Now he came with complaints of fever since 7 days , high grade , continuous , not relieved with medication associated with chills and rigor and associated with generalised body pains.
He had an episode of vomiting which is non bilious , non projectile with food particles as contents.
He complains of pain in lower abdomen which is of dull aching and non radiating since 3 days associated with burning micturition .
Since 2 days he has decreased urine output.
No complaints of cold , cough , shortness of breath
PAST HISTORY:
He underwent nephrectomy 24 years back ( donated kidney to his brother )
Known case of hypertension since 10 years and is on Telmisartan
He is also on furosemide since 10 years.
Not a known case of DM , TB , Asthma, epilepsy.
PERSONAL HISTORY:
Appetite - decreased since 15 days
Diet - Mixed
Bowel - regular
Bladder - Oliguria since 2 days associated with burning micturition
Sleep - Adequate
Addictions - Used to smoke 3 beedis / day and alcohol occasionally.
But stopped after nephrectomy
FAMILY HISTORY:
His brother had renal failure for which renal transplantation was done.
GENERAL EXAMINATION:
Patient is conscious , coherent, cooperative , moderately built and moderately nourished.
Pallor - Present
Icterus- absent
Cyanosis- Absent
Clubbing - absent
Generalised lymphadenopathy- absent
Pedal edema - Present. Pitting type ,extending till ankle .
Vitals : Temperature- afebrile
Pulse - 82 bpm
Blood pressure- 130/80 mmhg
Respiratory rate - 16cpm
SYSTEMIC EXAMINATION:
All quadrants moving equally with respiration
Nephrectomy scar is present
On auscultation , S1 S2 heard No murmurs .
RESPIRATORY SYSTEM:
Inspection:
Shape- elliptical
B/L symmetrical ,
Both sides moving equally with respiration .
Palpation:
Trachea - central
Expansion of chest is symmetrical.
Vocal fremitus - normal
Percussion:
Bilateral resonant note is heard.
Auscultation:
bilateral air entry present.
Normal vesicular breath sounds heard.
No added sounds.
CNS EXAMINATION:
Conscious
Speech normal
No signs of meningeal irritation
Gait : Normal
Cranial nerves: intact
Sensory system: intact
Motor system: intact
Reflexes: Right. Left.
Biceps. ++. ++
Triceps. ++. ++
Supinator ++. ++
Knee. ++. ++
Ankle ++. ++
PROVISIONAL DIAGNOSIS:
Acute on chronic kidney disease secondary to urinary tract infection.
Investigations:
1) Raised echogenicity of right kidney
2) normal size of kidney
Treatment:
3 sessions of haemosdialysis
Inj. Piptaz -2.25gm/tid
Tab. Lasix -40ug/po/ bd
Tab. Zofer -4mg/po/ sos
Tab. Dolo -650/ po/ sos
Tab. Pan 40mg /po/ od
Nebi. Duolin and Budecort 6hrly
Syr. Mucaine gel 15ml/po/ bd before meal 15min
Syrup. Cremaffin 15ml/po/ sos.
On auscultation :
S1 S2 heard
No murmurs
PER ABDOMEN:
All quadrants moving equally with respiration
No scars, sinuses and engorged veins , visible pulsations.
CENTRAL NERVOUS SYSTEM:
Conscious,coherent and cooperative
Speech- normal
No signs of meningeal irritation.
Cranial nerves- intact
Sensory system- normal
Motor system:
Tone- normal
Power- bilaterally 5/5
Reflexes: Right. Left.
Biceps. ++. ++
Triceps. ++. ++
Supinator ++. ++
Knee. ++. ++
Ankle ++. ++
PROVISIONAL DIAGNOSIS:
Fibrosis of right upper lobe
