55/M with anuria and distended abdomen.
A 55 year old man, resident of Yadagirigutta has come with complaints of reduced urine output since yesterday (01/08/2022) night 10pm
History of presenting illness
Patient was apparently asymptomatic 20 days ago, then had fever with evening rise of temperature and chills. He went to a hospital 2 days later and was given medication. He went for a checkup 5 days later and was found to have reduced WBC count and was given medication. He went for a checkup a week later and had found out to have jaundice.
3 days ago, he had fever with yellowish discolouration of eyes(Serum bilirubin was 2.4mg/dl) and pedal edema(upto ankle).
Since yesterday(01/08/2022) night 10pm, he has not passed urine, his abdomen is distended and he has shortness of breath.
Past history
History of fracture of head of femur in Jan 2022. He underwent reconstructive surgery with prosthesis and was on advised bed rest for 2 months
N/k/c of Diabetes, hypertension, epilepsy, asthma, CAD, Thyroid disorders,Tuberculosis
Personal history:
Appetite: normal
Diet: mixed
Bowel movements: no stools were passed today(02/08/2022)
Bladder movements: reduced urine output
Addictions: He has been consuming alcohol for the past 20 years now (180 ml per day). He stopped taking alcohol for the past 20 days now.
He’s been smoking for 1 year now (1 cigarette per day). He stopped smoking since the last 20 days.
Daily routine
He wakes up at 6 AM in the morning and goes for a walk. He gets back home and has tea by 7:30 AM.
He has his brunch by 9:30 AM and heads out. He takes an active part in resolving the issues of his fellow villagers. He gets back home (usually drunk) by 8 PM, has his dinner and off he goes to bed by 9 PM.
Family history:
General examination:
Patient is conscious, coherent and cooperative
He is moderately built and moderately nourished
Icterus is present
B/l pedal edema upto the ankle pitting type
No pallor, cyanosis, clubbing, lymphadenopathy
Vitals:
Temperature: Afebrile
Pulse rate:92bpm
Blood pressure:
Respiratory rate:29cpm
SpO2: 98%
Grbs:
Respiratory system:Bilateral air entry-present ,Normal vesicular breath sounds-heard
Cardiovascular system:
S1 and S2 heard no murmurs heard
Central nervous system:
Higher motor functions:
MMSE: couldn't be assessed
Speech:
Signs of meningeal irritation-present
Neck stiffness-present
Brudzinski sign-
Kerning sign-
Motor:
Right left
Tone: UL normal normal
LL normal normal
Power:UL couldn't assess
LL couldn't assess
Reflex:
Superficial reflexes: Right left
Corneal
Conjunctival
Deep tendon reflexes:
Biceps
Triceps
Supinator
Knee ++ ++
Ankle + +
Plantar extensor extensor
Sensory: Right left
Touch
Pain
Vibration
Cerebellar functions:couldn't be assessed
Gait: couldn't be assessed
Provisional diagnosis:
Acute kidney injury and acute liver injury
Uremic encephalopathy.
Investigations :
ECG ON 2-8-2022
ECG ON 4-8-2022:
Treatment:
On 3-8-2022:
Inj.PAN 40 g I.v OD
Inj. CEFTRAONN 1gm I.v BD
Inj. LASIX 20mg I.v BD
Inj. DOXY 100mg I.v BD
Tab. ADICTONE 25mg p.o BD
Tab. UDILI 300mg p.o BD
Tab. UITRACET 1/2 P.o BD
SYR. LACTULOSE 10ml p.o BD
Neb. ASTHALINE p.n BD
I.v NS RL @30ml/hr
Inj.TRAMADOL plus NS 300ml.
On 4-8-2022:
Inj.PAN 40 g I.v OD
Inj. CEFTRAONN 1gm I.v BD
Inj. LASIX 20mg I.v BD
Inj. DOXY 100mg I.v BD
Tab. UDILI 300mg p.o BD
Tab. UITRACET 1/2 P.o BD
SYR. LACTULOSE 10ml p.o BD
Neb. ASTHALINE p.n BD
Inj.TRAMADOL 1ampi.v
Tab.DOLO 650mg p.o sos
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