38 year old male patient with decreased appetite, decreased urine output and fever

 Name- M. Sri Nithya


Roll. No- 75


 I’ve 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. 

Following is the view of my case: (history as per date of admission)


38 year old male patient came to the casuality with the chief complaints of 

Decreased appetite since 3-4 months
Fever since 3 months(on and off) aggravated during last 10 days
Decreased urine output since 15 days

History of present illness:

Patient was apparently asymptomatic 4 months ago then 
 He developed decreased appetite and
 
Fever since 3 months which is insidious in onset, gradually progressive, intermittent, aggravated during last 10 days. It is associated with chills not associated with rigor. It relieved on medication.

There is decreased urine output since 15 days. 
 
There is no history of blood in urine, facial puffiness,pedal edema, pain in the abdomen, chest pain, shortness of breath, palpitations.

Past History:

There is no history of TB, asthma, hypertension, diabetes mellitus, cardiovascular diseases.

No H/O previous surgeries.

Personal history

Appetite- normal

Diet -mixed

 bowel and bladder -regular

Sleep- adequate

Addictions-He is a chronic smoker since 10 years

He is  chronic alcoholic since 15 years

No known allergies.


Family history

No significant family history.


General examination

Patient is examined in a well lit room with informed consent. 

He is conscious, coherent, co-operative,well oriented to time,place and person.

He is moderately built and moderately nourished.

Pallor - present

Icterus - absent

Cyanosis - absent

Clubbing - absent

Lymphadenopathy - absent

Edema - absent


Vitals:

Temperature-afebrile
Heart rate-90 beats/min
Blood pressure-110/70 mmHg
Respiratory rate-22cycles/min
SPO2-98% at room air.
Grbs- 140 mg%

SYSTEMIC EXAMINATION:

CVS: S1 and S2 heard
         No added thrills, murmurs

RESPIRATORY SYSTEM: 

Trachea is central,
Normal vesicular breath sounds were heard on both sides.
There is no dyspnoea or wheeze. 


CENTRAL NERVOUS SYSTEM: 
Level of consciousness : conscious to time, place, person
Speech: normal
Cranial nerves -Normal
Motor and sensory: normal 

INVESTIGATIONS












Diagnosis:  Acute kidney injury on CKD. secondary to post renal obstruction ( ureteric obstruction) with B/l hydronephrosis.


Treatment: 

Inj. Lasic 40 mg I.V OD 

Tab. Nodosis 500 mg BD

Tab. Shelcal ct OD

Tab. Orofer BD

Inj. Erythropoeitin 4000 IU S/c weakly once

Inj. Iron sucrose 1ampoule 500 ml





Comments

Post a Comment

Popular posts from this blog

70yr old male with altered sensorium secondary to ?Meningitis

Image
  Sri Nithya Roll.no-86 ICU-BED. NO -03 A 70 Years Old Man Who was a Farmer By Occupation Presented to Casualty With  Altered Sensorium Since 3 Days  Fever Since 20 Days  HOPI :  Patient Was Apparently Asymptomatic Till 2014 ; 2014 - Patient Had Fever Associated with Cough for which he went to Hospital & Was Diagnosed to Have ? Pneumonia with DENOVO DM2 & Was Prescribed with OHAs ( Tab.METFORMIN & Tab.GLIMIPRIDE ) 6 Months Back - Patient Had Fever Associated with Cough for Which he Went to Hospital & Said to Have High Sugars along with Lung Infection ; Got Treated & Discharged in a Hemodynamically Stable Manner.Started using insulin for Diabetes Since Then  20 Days Back : Patient Had Fever with Cough ; For Which He went to Hospital & Suspected to Have TB But Reports Turned out to be Negative & Patient Discharged as LAMA & When He Returned Home 3 Days Back He Gradually Developed Altered Sensorium & Couldn't Recognise His Attendants Past History :
Read more
Image
  CASE-1 1) Pulmonology (10 Marks)    A) Link to patient details:     https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html   Questions:   1) What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem?   2) What are mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient?   3) What could be the causes for her current acute exacerbation?     4. Could the ATT have affected her symptoms? If so how?     5.What could be the causes for her electrolyte imbalance?   1)EVOLUTION OF EVENTS OF SYMPTOMATOLOGY    1)shortness of breath which is on and off since 20 years.     2)pedal  edema since 15 days up to the level of the ankle, pitting type. 3)facial puffiness since 1
Read more

70 year old female with complaints of slurring of speech

Image
  M. Sri Nithya Roll. No-86 Unit-2 70 year old female was brought to the casualty with complaints of slurring of speech in morning for 15 minutes at 8am following which patient returned to normal  No loc, seizure like activity, drooling of saliva,deviation of mouth ,no weakness of limbs, No H/O Fever; Headache; Giddiness No H/O Chest pain; orthopnea; sweating, palpitations;, PND. No H/O Burning Micturition No H/O loose stools; Nausea, Vomiting Was treated by local practioner with unknown medications Patient continued her daily routine cooking,eating At around 7pm patient developed similar episode lasting for 15 minutes Was taken to Mothkur for treatment and was given clopidogrel a ,neurobion  ( no investigations were done) On the way back to the home , patient developed deviation of mouth ,uprolling of eyeballs, dif haficulty in moving lower limbs with decreased responsiveness Brought to our hospital for further management  Daily wage labourer ( agriculture) Stopped working 20years bac
Read more