80 year old male with oliguria

Hall ticket number : 1701006086

Name - K.Keshitha 

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CHIEF COMPLAINTS:

80 year old male patient came with chief complaints of 

    Decreased urine output since 2 days 

    Pain in the abdomen since 2 days 

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 10 years back then  he developed fever which was continuous ,not  relieved on medication and  associated with chills and rigors  and decreased urine output for  which he went to a hospital and was diagnosed with acute renal failure and had three sessions of dialysis.He was also diagnosed with hypertension and is on regular medication(Telmikind) since then.

He had recurrent episodes of burning micturition with increased frequency and dysuria for which he took symptomatic treatment.

Now he came with complaints of fever since 7 days , high grade , continuous , not relieved with medication associated with chills and rigor and associated with generalised body pains.

He had an episode of vomiting which is non bilious , non projectile with food particles as contents.

He complains of pain in lower abdomen which is of dull aching and non radiating since 3 days associated with burning micturition .

Since 2 days he has decreased urine output.

No complaints of cold , cough , shortness of breath

PAST HISTORY:

He underwent nephrectomy 24 years back ( donated kidney to his brother )

Known case of hypertension since 10 years and is on Telmisartan

He is also on furosemide since 10 years.

Not a known case of DM , TB , Asthma, epilepsy.

PERSONAL HISTORY:

Appetite - decreased since 15 days 

Diet - Mixed 

Bowel - regular 

Bladder - Oliguria since 2 days associated with burning micturition

Sleep - Adequate 

Addictions - Used to smoke 3 beedis / day and alcohol occasionally.

But stopped after nephrectomy 

FAMILY HISTORY:

His brother had renal failure for which renal transplantation was done.

GENERAL EXAMINATION:

Patient is conscious , coherent, cooperative , moderately built and moderately nourished.

Pallor - Present

Icterus- absent 

Cyanosis- Absent

Clubbing - absent

Generalised lymphadenopathy- absent 

Pedal edema - Present. Pitting type ,extending  till ankle .

Vitals : Temperature- afebrile

             Pulse - 82 bpm

             Blood pressure- 130/80 mmhg

             Respiratory rate - 16cpm 

SYSTEMIC EXAMINATION:

PER ABDOMEN:

Inspection - 

          Umbilicus - inverted
          All quadrants moving equally with respiration
          Nephrectomy scar is present

          No sinuses and engorged veins , visible pulsations. 

          Hernial orifices- free.

Palpation -  

soft, non-tender

no palpable spleen and liver

Percussion - tympanic note heard 

Auscultation- normal bowel sounds heard. 

                

CARDIOVASCULAR SYSTEM:

Inspection:

Shape of chest- elliptical 

No precordial bulge or pulsations 

JVP - not raised 

Palpation:

Apical impulse was felt at 5th intercoastal space 1 cm medial to mid clavicular line

On auscultation , S1 S2 heard  No murmurs .

RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: 

Bilateral resonant note is heard.

Auscultation:

 bilateral air entry present. 

Normal vesicular breath sounds heard.

No added sounds.

CNS EXAMINATION: 

Conscious 

Speech normal

No signs of meningeal irritation 

Gait : Normal

Cranial nerves: intact

Sensory system: intact

Motor system: intact

Reflexes: Right.     Left. 

Biceps.      ++.          ++

Triceps.    ++.          ++

Supinator ++.         ++

Knee.         ++.         ++

Ankle        ++.         ++

PROVISIONAL DIAGNOSIS:

Acute on chronic kidney disease secondary to urinary tract infection.

Investigations:

Complete blood picture:

Hb - 5.8 gm/dl

TLC -  14000 cells/ cumm

RBC - 1.8 million

PLT -  90,000 cells

Complete urine examination.

Colour- pale yellow 

Albumin- negative 

Sugars- negative 

Pus cells- plenty

Epithelial cells- 1 to 2 cells/ HPF

URINE CULTURE:

Moderate amount of pus cells seen and 

E.COLI Organism is isolated and is sensitive to all antibacterials.

RFT: 

urea - 129 mg/dl

Creatinine - 6.3 mg/dl

Electrolytes:

Na  - 137 mEq/L

K - 4.4 mEq/L

Cl - 104 mEq/L 

LFT :

 Total bilirubin- 0.63 mg/dl

 ALT - 10 IU/L

 AST - 38 IU/L

 ALP - 258 IU/L

 albumin - 2.98 gm/dl

 A/ G ratio - 1.41

USG REPORT :

1) Raised echogenicity of right kidney 

2) normal size of kidney

3) mild hydronephrosis

4)Left kidney is not visible 

ECG  REPORT

CHEST X-RAY:

Treatment: 

3 sessions of haemosdialysis 

Inj. Piptaz -2.25gm/tid

Tab. Lasix -40ug/po/ bd

Tab. Zofer -4mg/po/ sos

Tab. Dolo -650/ po/ sos

Tab. Pan 40mg /po/ od

Nebi. Duolin and Budecort 6hrly

Syr. Mucaine gel 15ml/po/ bd before meal 15min

Syrup. Cremaffin 15ml/po/ sos.