THIS IS AN 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT
CHEIF COMPLAINTS
A 65 YEAR OLD MALE TODDY TREE CLIMBER BY OCCUPATION CAME WITH C/O ANURIA BEFORE 4DAYs
SOB GRADE -2-3
HOPI
PATIENT WAS APPARENTLY ASYMPTOMATIC 15 YEARS BACK , PATIENT SUDDENLY FELL FROM TODDY TREE WHILE CLIMBING HAD HISTORY OF FRACTURE OF FEMUR WHICH ORIF WAS DONE .
AGAIN 10 YEARS BACK PATIENT HAD C/O FALL DUE TO GIDDINESS , DIAGNOSED WITH HYPERTENSION AND SINCE THEN ON REGULAR MEDICATION
Patient Has Got Flexion Fixed Deformities 7 Year Back . Stays In Home and stopped Climbing Toddy Trees .
Then after 5 years he had h/o fall ,had #tibia, no treatment was done
From then he was unable to walk even with support
His place of living is endemic to flourine He Stopped Drinking Bore Water From 10 years
PATIENT CAME WITH C/O ANURIA BEFORE 5DAYS WHICH WAS SUDDEN ONSET
SOB GRADE 2-3
ORTHOPNEA : NEGATIVE
PND : NEGATIVE
NO C/O CHEST PAIN ,
NO C/O PALPITATION
NO C/O SYNCOPAL ATTACKS
NO H/O FEVER
NO BURNING IN MICTURITION
NO ABDOMINAL PAIN
NO ABDOMINAL DISTENTION
C/O URINARY URGENCY PRESENT
INCOMPLETE VOIDING OF URINE PRESENT
PAST HISTORY:
PATIENT HAD RENAL CALCULII AND UNDERGONE SURGERY
NOT A KNOWN CASE OF DM , CVA ,CAD , TB , ASTHMA
As told by the patient and his attenders
First he had h/o fall from tree 9-10 yrs back,had #femur ,ORIF was done. He used to walk with support for few months
Then again he had h/o fall at his home,
# hip
TREATMENT HISTORY :
FOR HYPERTENSION - TAB.AMLONG 5 MG PO / OD
SURGERY DONE FOR RENAL CALCULI
PERSONAL H/O :
APPETITE - DECREASED
BOWELS - IRREGULAR
MICTURITION - ABNORMAL
ADDICTIONS :-
OCCASIONALLY ALCOHOL CONSUMPTION
SMOKING H/O PRESENT
FAMILY H/O :- NOT SIGNIFICANT
GENERAL EXAMINATION :
PATIENT IS CONSCIOUS, COHERENT,
COOPERATIVE,WELL ORIENTED TO TIME,PLACE,PERSON.
SIGNS OF PALLOR AND PEDAL EDEMA PRESENT
NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY.
VITALS :-
TEMPERATURE - 98.6 F
PULSE - 100 BPM
RR - 16 CPM
BP - 160/90 MMHG
Spo2 - 98 % @ ROOM AIR
GRBS: 106MG%
CVS - S1S2 HEARD , NO MURMURS
CNS - INTACT
RS :- DYSPNOEA PRESENT ; BREATH SOUNDS - VESICULAR ; B/L IAA , ISA CREPTS PRESENT
PER ABDOMEN : SOFT, NONTENDER
PATIENT NECK IS RIGID,WHEN HE SLEEPS ON BED
HIS NECK IS IN ELEVATED POSITION PROBABLY DUE TO SPONDYLOSIS OF CERVICAL VERTEBRAE
INVESTIGATIONS
x-ray KUB
HEMOGRAM-7/02/2022
RFT-07/02/2022
24hr URINARY PROTEINS-07/02/2022
CUE
HEMOGRAM.
Hb: 9.6.
TLC: 15,200
N/L/C/M/B=86/7/1/7/0
PCV : 30.5
MCH : 86.9
MCHC : 31.5
RDW-CV : 15.6
RDW-SD : 51.0
RBC Count : 3.51
PLT : 2.54
PS : NC/NC Neutrophilic leucocytos's
SPOT URINE : PROTEIN CREATININE RATIO :3.74
RBS: 179
LFT :-
TB - 0.8
DB: 0.16
SGOT - 13
SGPT : 10
ALP: 599
TP: 5.8
A: 3.4
A/G: 1.40
RFT:
Blood Urea 111
Sr Creat : 5.2
Na+ : 138
K+ : 5.7
Cl– : 102
Uric Acid : 9.7
CHEST X-RAY PA-VIEW
XRay Both The Knees:-
X-RAY LEFT KNEE LATERAL VIEW
X-RAY RIGHT KNEE LATERAL VIEW
X-RAY SPINE LATERAL
ECG
2D ECHI
FEVER CHART
PROVISIONAL DIAGNOSIS
AKI SECONDARY TO ? ACUTE URINARY RETENTION
TREATMENT PLAN:
1)Inj. Meropenem 500mg / IV/BD(Antibiotic)
2) Inj. LASIX 40mg/IV/BD(furosemide-loop diuretic)
3 ORAL FLUIDS ~2L.
4) Inj. PAN 40mg /IV/OD
5) Nebulization with DUOLIN(salbutanol-btonchodialator) & Budecort(STEROID)8th hourly
6) Tab. AMLONG 5mg po/OD(AMLODIPIN-Calciun channel blocker)
DAY - 2 AMC BED-4 65yrs/M
S : ONE SESSION OF HAEMODIALYSIS WAS YESTERDAY (INDICATION OF DIALYSIS - ANURIA SINCE 1 DAY)
0 : TEMP - AFEBRILE
BP - 130/90 MMHG
PULSE -86 BPM
RR - 20 CPM SPO2 98% @ RA
CVS -S1S2+, NO MURMURS
RS - BAE +
PA - SOFT, NON TENDER
A : AKI ON CKD??? WITH LEFT RENAL CALCULUS SIZE 4MM B/L HYDRONEPHROSIS
1)Inj. Meropenem 500mg / IV/BD
2) Inj. LASIX 40mg/IV/BD
3 ORAL FLUIDS ~2L.
4) Inj. PAN 40mg /IV/OD
5) Neb with DUOLIN & Budecort 8th hourly
6) Tab. AMLONG 5mg po/OD
STRICT I/O CHARTING
WARD DAY 3 65/M
S: URINE OUTPUT INCREASED
-1700ml
O: ONE SESSION OF HEMODIALYSIS DONE ON 3/02/2022
TEMP - AFEBRILE
BP - 130/90 MMHG PULSE82 BPM
RR - 20 CPM
SPO2 - 98% @ RA
CVS - S1S2+, NO MURMURS
RS - BAE +
PA - SOFT, NON TENDER
A: AKI ON CKD??? SECONDARY TO BPH ?, URETHRAL STRICTURE? WITH LEFT RENAL CALCULUS SIZE 4MM B/L HYDRONEPHROSIS
P
1) Inj. Meropenem 500mg / IV/BD
2) Inj. LASIX 40mg/IV/BD
3 ORAL FLUIDS ~2L.
4) Inj. PAN 40mg /IV/OD
5) Neb with DUOLIN & Budecort 8th hourly
6) Tab. AMLONG 5mg po/OD
STRICT VO CUARTING
DAY - 4 WARD 65yrs/M
S: Urineoutput Improved , No fresh Complaints
0 : ONE SESSION OF HAEMODIALYSIS WAS YESTERDAY (Total - 2 Dialysis )
TEMP - AFEBRILE
BP - 130/70 MMHG
PULSE - 96 BPM
CVS -S1S2+, NO MURMURS
RS - BAE +
PA - SOFT, NON TENDER
A : PostRenal AKI Secondary to B/L Ureteric Calculi
- Moderate Hydrouretero Nephrosis with left Renal Calculi
P :
1) Inj. Meropenem 500mg / IV/BD
2) Inj. LASIX 40mg/IV/BD
3 ORAL FLUIDS ~2L.
4) Inj. PAN 40mg /IV/OD
5) Neb with DUOLIN & Budecort 8th hourly
6) Tab. AMLONG 5mg po/OD
STRICT I/O CHARTING
DAY - 5 WARD 65yrs/M
S: Urineoutput Improved , Patient complainting Of Loss Of Appetite , No Fever Spikes
0 : HAEMODIALYSIS (Total - 2 Dialysis ) .
Output - 1800ml
Input - 1600ml
TEMP - AFEBRILE
BP - 130/80 MMHG
PULSE - 96 BPM
CVS -S1S2+, NO MURMURS
RS - BAE +
PA - SOFT, NON TENDER
A : PostRenal AKI Secondary to B/L Ureteric Calculi and Bladder Calculi
- Moderate Hydrouretero Nephrosis with left Renal Calculi
- OPLL / DISH
1)Inj. Meropenem 500mg / IV/BD
2) Inj. LASIX 40mg/IV/BD
3 ORAL FLUIDS ~2L.
4) Inj. PAN 40mg /IV/OD
5) Neb with DUOLIN & Budecort 8th hourly
6) Tab. AMLONG 5mg po/OD
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