80 year old with decreased urine output
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PREITY YARLAGADDA
ROLL NO 145
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 diagnosis and treatment plan.
December 14, 2021.
CASE :
A 80 year old male patient came to the casualty with the chief complaints of
- burning micturition since 15 days
- fever since 5 days
- decreased urine output since 4 days,
- Hematuria for 3 days
History of present illness :
- Patient was apparently normal 8 years back then he had pain abdomen which was associated with fever and vomitings and he was diagnosed with Liver abscess and needle aspiration was done.
- Then 4 years back patient developed a blister over right ankle which ruptured and formed an ulcer and cellulitis debridement was done.
- Since 15 days the patient complaints of burning micturition which was associated with fever, nausea, vomitings.
- Fever since 4-5 days which was intermittent and not associated with chills and rigors. No aggravating factors but reduced on taking medication.
- The patient also complaints of on and off edema in the legs.
- The patient had hematuria after insertion of Foley's catheter and it reduced later.
- No h/o loose stools, facial edema
Past history :
- Not a known case of HTN, DM, Asthma, epilepsy.
- Diet - Veg
- Appetite - Normal
- Sleep - Adequate
- Bowel movement - Regular
- Bladder movement - decreased with burning sensation.
- Addictions - None
General examination :
The patient was examined in a well lit room after taking consent.
- Patient is drowsy but arousable.
- He is thin built and malnourished.
- No pallor, icterus, cyanosis, clubbing, edema and lymphadenopathy.
Vitals :
- Temp : Afebrile
- BP : 100/60 mm Hg
- PR : 86 bpm
- RR : 22 cpm
- GRBS : 100 mg / dl
- SpO2 : 98 % @ RA
Systemic Examination :
- CVS : S1S2 + , No murmurs
- RS : BAE + , NVBS +
- P/A : Soft , Nontender , BS +
- CNS : HMF intact
Provisional diagnosis :
Uremic encephalopathy
Post renal AKI secondary to vesical calculus.
Chronic cystitis and pyelonephritis
Prostatomegaly grade 1
Plan of treatment :
- INJ.PCM 1 GM /IV/SO
- INJ.PAN 40MG/IV/SO
- INJ.ZOFER 4MG/IV/TI
- IVF NS@UO+30ML/H
- TAB.NICARDIA 10 MG/PO/STA
- BP/PR/TEMP MONITORING 4TH HOURL
- TAB. NODOSIN 500MG/PO/TI
- INJ.PIPTAZ 4.5GM/IV/STATDYTRDSS
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