50 yr old farmer with decreased urine output


Chief complaints 

C/o SOB since 1 week 

C/o swelling in the legs 

C/o decreased urine output 


HOPI

A 50 yr old Farmer doing his regular work, of driving tractor till one week ago when he had sob with sweating, taken to a doctor outside ,where his grbs was recorded low ,was revived with eating a chocolate only, but he continued to take his oha even after that,rft showed increased creatinine,since 3 days his symptoms aggrevated and was brought here for further management ,2 sessions of dialysis 

1 st -19/2/22 from 10 am to 2 pm , 2 nd - 20/2/22 were done  



PAST HISTORY 

known case of DM since 3 years on medication 

HTN since 6 months (giddiness first symptom )

NO H/o asthma ;TB;EPILEPSY



PERSONAL HISTORY 

Marital status - married 

Occupation - Farmer 

Appetite - Normal 

Diet - Decreased appetite 

Bowel and bladder movements - regular

Addictions - 

Chronic alcoholic since 20 years daily 180 ml.

Chronic smoker since 20 years  daily 2-4 beedis per day.

No significant family history .


GENERAL EXAMINATION :

Patient is conscious , coherent, cooperative 

Pallor positive 

No icterus , cyanosis , lymphadenopathy, edema .



Systemic examination 


VITALS

BP : 120/ 80MM HG

PR : 86/ MIN

RR : 16/ MIN

SPO2: 98% on RA

GRBS : 105 mg/dl


SYSTEMIC EXAMINATION

CVS : S1, S2 +

RS : BAE +

P/A : soft , nontender 

CNS : No findings 



Investigations 

Blood group 
A positive 
CBP 
Hb - 6 
TC - 15,200 
N- 90 
L-05 
E - 02 
M- 03 
B-00
 SEROLOGY- NEGATIVE 

LFT - 
TB- 1.24 
DB -0.30 
SGOT - 15 
SGPT - 19 
ALP -198 
TP - 6.3
ALB -3.5

RFT - 
UREA - 271 
CREATININE - 12.0
CALCIUM - 7.7 
PHOSPHORUS -8.4
SODIUM - 133 
K- 4.9
Cl - 96 


SERUM IRON 
86 UG/DL 

TROP I 
NEGATIVE 
 
BLOOD SUGAR -FASTING 
FBS - 217 








Provisional diagnosis 
ACUTE LVF 2 TO LATERAL WALL MI ? With CKD 2 to DIABETIC NEPHROPATHY ?
WITH K/C/O DM AND HTN WITH PULMONARY OEDEMA 

Treatment 

1) INJ LASIX 40 mg/Iv/tid 
2)INJ pan 40 mg Iv/OD 
3) Tab nodosis 500 mg PO/BD 
4) tab shelcal c PO/OD 
5) tab orofer xt PO /OD 
6) INJ HAI s/c 8 am -2pm-8 pm 
7) monitor vitals and check Grbs 4 TH hourly 






































Comments

Post a Comment

Popular posts from this blog

30 year old RENAL TRANSPLANT RECIPIENT with deranged RFT

Image
 Chief complaints  Renal transplant recipient came with deranged RFT values on routine investigation done for his renal transplant came to kamineni on 7/2/22 No c/o pedal odema  No c/o SOB ,facial puffiness  HOPI  Patient was apparently asymptomatic then on routine investigation done for renal transplantation revealed elevated creat levels  Sr creat - 3.5mg/dl  Urea - 85 mg/dl  No h/o decreased urine output ,urinary retention Past history  H/o previous admissions for dialysis for 2 years (CRF)  K/c/o HTN on tab amlong 10 mg - 5 mg - 10 mg  Tab.arkamime 0.2 mg po/tid  H/o 2 times intubation and extubation i/v/o pulmonary oedema , hypertensive emergency and resistant hypertension 2 years back  H/o loculated pleural effusion and icd drainage 2 years back  Treatment history  K/c/o htn on tab amlong and arkamine  Surgical history  K/c/o renal transplant recipient  Personal history  Single  Appetite - normal  Bowel and bladder movement - normal  No known addictions  Family history - not sign
Read more

44 year old with ALD

Image
  CHIEF COMPLAINTS   44 year old male came to casualty with chief complaints of fever with chills on and off high grade associated with chills and rigor  HOPI  patient was apparently asymptomatic 12 years back had history of intake of alcohol initially 90 ml   gradually progress to amount of 200 ml  since 2 years patient was on alcohol 200 ml , quantity increased to daily intake  of with no  or minimal food intake H/O agressive behaviour  tremors +  decreased appetite  yellowish discoloration of sclera present  vomiting of 1 episode , patient was admitted in outside hospital and treated as alcoholic liver disease With TB - 23.7 gradually reduced to 2.5   pain abdomen +  passing stools (1-2 ) episodes/day  No loose stools , vomitings,malena ,blood in stools  Past history  N/K/C/O - DM, ASTHMA,TB , EPILEPSY Personal history  married  appetite - lost  bowel - regular  micturition - normal  known alcoholic since 12 years  GENERAL EXAMINATION  no pallor,icterus,cyano
Read more