75 year old male patient with decreased urine output and shortness of breath LONG CASE


This is an online elog book to discuss our patients de-identified health data shared after taking his/her/guardians signed informed consent.Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This elog book reflect s my patients centered online portfolio and your valuable inputs on the comments is welcome

Date of admission: 10/01/23

Chief complaints: Patient was brought to the casualty with chief complaints of decreased urine output since 1 week and shortness of breath since 1 week

History of present illness: Patient was apparently asymptomatic 3 months back and then he developed lower limb cellulitis of left leg and debridement was done with dressings.
Patient had uncontrolled sugars with 500mg/dL blood sugar level, and was diagnosed with UTI
Burning sensation of right lower limb 
Burning micturition and was treated with antibiotics and had difficulty in passing stools. He drnk castor oil then passed 7to 8 stools.
Patient developed decreased urine output and shortness of breath of grade 1 which increased on lying down and relieved with sitting position, and relieved after hemodialysis
4 sessions of hemodialysis was done 
PRBC transfusion was done.

History of past illness: patient is a k/c/o DM since 12 years and is on medication Glimp m2 po/bd
k/c/o of HTN stamlo 5mg po/bd
Known case of Chronic kidney disease since 5 years 

FAMILY HISTORY:
No similar complaints in family 

PERSONAL HISTORY: 
APPETITE : Normal
DIET: mixed 
SLEEP : disturbed
BOWEL: constipation
MICTURITION : decreased 
Addictions: Alcohol daily since 12 years upto 1 year back
Tobacco upto 3 months back

Clinical examination: 
GENERAL EXAMINATION
Patient is drowsy
• Pallor - absent
• Icterus - Absent 
• Clubbing - Absent 
• Koilonychia - Absent 
• Lymphedenopathy - Absent 
• Pedal oedema - absent 
VITALS
• Temperature - 99°F 
• Pulse rate - 98bpm
• Respiratory rate - 20 cpm
• BP - 160/80 mmHg
• SPO2 - 97% on room air 




Systemic Examination:

CARDIOVASCULAR SYSTEM:
No Thrills, 
S1,S2 sounds heard
No murmurs. 
Raised JVP

RESPIRATORY SYSTEM:
INSPECTION:
Chest is symmetrical
Trachea:central
PALPATION:
Trachea:central
AUSCULTATION:
Vesicular breath sounds
Dyspnoea and wheeze present
Bae present
Crepts are heard


ABDOMEN:
INSPECTION:
shape-obese
Flanks-full
Umbilicus-everted and central position 
Hernial orifices-nornal
No dilated veins 
No scars and sinuses 
PALPATION:
Non tender
No Local rise of temperature 
No palpable Mass 
Spleen and liver not palpable 
AUSCULTATION:
Bowel sounds-present

CNS:
Patient is drowsy
Speech is incoherent
No signs of meningeal irritation
Cranial nerves are intact
Glass gow coma scale: E-4, V-2, M-6
Reflexes:
Right
Biceps+
Triceps+
Supinator+
Knee+
Ankle-
Left
Biceps+
Triceps+
Supinator+
Knee-
Ankle-
Provisional diagnosis: 

Investigation



Diagnosis: Acute kidney injury on Chronic kidney Disease with cellulitis of left lower limb
Treatment:
Inj lasix 100mg iv stat
Tab nicardia 20mg
Tab nodosis 500mg
Rules tube feeding every 4th hour

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