65Y MALE WITH C/O ANURIA

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 

A 65 YEAR OLD MALE TODDY TREE CLIMBER BY OCCUPATION CAME WITH C/O ANURIA SINCE YESTERDAY 12 PM . 

HOPI: 

H/0 RENAL CALCULI 20 YEARS BACK. SHORTNESS OF BREATH GRADE 2 - 3 SINCE YESTERDAY 12 P.M. 

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 . He Stopped Drinking Bore Water From 10 years  

PATIENT CAME WITH C/O ANURIA SINCE YESTERDAY 12 PM, SUDDEN ONSET 

SOB GRADE 2-3

ORTHOPNEA : NEGATIVE

PND : NEGATIVE

NO C/O CHEST PAIN , PALPITATION , SYNCOPAL ATTACKS

C/O URINARY URGENCY PRESENT

INCOMPLETE VOIDING OF URINE PRESENT

PAST HISTORY: 

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 after 5 years he had h/o fall ,had #tibia, no treatment was done

Then again he had h/o fall at his home, ?# hip

From then he was unable to walk even with support

TREATMENT HISTORY : 

FOR HYPERTENSION - TAB.AMPONG 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 

INVESTIGATIONS : 

ULTRASOUND 

                     XRay KUB

                   NCCT - KUB

RFT - 7/2/22

                   HAEMOGRAM - 7/2/22

                 24 hr Urine Protein 

                     CUE    6/2/22

Urine Microscopy Image

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 Xray PA View

XRay Both The Knees 

xray left Knee lateral View

Xray Right Knee Lateral View

Xray Cspine Lateral 

ECG 

2D ECHO 

2D echo

FEVER CHARTING 

PROVISIONAL DIAGNOSIS

AKI SECONDARY TO ? ACUTE URINARY RETENTION

TREATMENT PLAN: 

IV FLUIDS 2 U NS & 2 U RL @ 100 ML / HR

INJ LASIX 40 MG IV / BD

INJ PAN 40 MG IV / OD

NEBULIZATION WITH DUOLIN & BUDECORCT 8TH HOURLY

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

P

1) Inj. AUGMENTIN 500mg / IV/BP

2) Inj. LASIX 40mg/IV/BD

3 ORAL FLUIPS ~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

P

1) Inj. Meropenem 500mg / IV/BD

2) Inj. LASIX 40mg/IV/BD

3 ORAL FLUIDS ~2L.

4) Tab. AMLONG 5mg po/OD

STRICT I/O CHARTING