70 year old male patient

GM Blog: 70 year old male patient 


NOTE
This is an ongoing case and will be updated 
The reference link (if any) will be mentioned at the bottom.

Date of admission: 7-10-2022

CHIEF COMPLAINT: patient came to the opd with complaints of anuria, shortness of breath and swelling in the leg.

HISTORY OF PRESENT ILLNESS-
Patient was apparently asymptomatic 20 days back then he developed swelling in the feet.
On 8 th oct , he didn't pass urine in the entire day and was brought to the opd.
He also had shortness of breath. 

PAST HISTORY:

Two years ago, the patient was in a road traffic accident where he fell from his bike near his village in Nalgonda. He fractured his left leg near his hip and underwent a surgical procedure where rod(s) were inserted to ensure proper healing. He has been unable to work ever since and has become bedridden.
He is unable to walk or sit on his own. 
He has been taking painkillers (NSAIDs) for hip pain since the past 6 months. 
He has history of diabetes since 10-15 years for which he is taking medication (Metformin 500 mg once daily)

Not known case of Tuberculosis,leprosy, Cardiovascular diseases,chornic kidney disease and any other chronic illness
 
PERSONAL HISTORY:
Married 
Farmer 
Diet: mixed. ( Non vegetarian)
Moderately built and nourishment.
Appetite -decreased
Bladder movment- anuria 
Bowel movements- normal 
Allergy-no 
Addiction- bidi completes 1 stack in 2 days since childhood 


FAMILY HISTORY:
Not significant 

GENERAL EXAMINATION:
Patient is conscious, coherent, co-operative.
He is well oriented to time, place and person. 
He is moderately built and nourished  
Pallor - present 
icterus absent
No cyanosis
No clubbing
Pedal edema present ( non pitting)
No Lymphadenopathy 

Vitals 
Pulse rate: 97/min
Afebrile to touch.
Respiratory rate 28/min
BP: 140/90 mm of Hg
O2 saturation 98% (with O2 therapy)

Systemic examination

CVS
Cardiac sounds S1 and S2 present.
No thrills or murmurs.
Apex beat heard in 6th intercostal space lateral to mid clavicular line

Respiratory system
Chest is symmetrical, barrel shaped on inspection.
No visible deviation of the trachea, supraclavicular hollowing or unilateral sternocleidomastoid prominence.
No drooping of either shoulder.
There appears to be a retraction near the 7th intercoastal space on both sides.

On palpation, inspectory findings were confirmed. Trachea in midline, no intercoastal crowding, no rosary beads appearance at costochondral junctions. Pain is present at the site of retraction in the 7th intercoastal space. No dilated veins. Chest movements were normal, symmetrical. Tactile fremitus was more apparent on the right side.

On percussion, no dullness or abnormality was noted.

On auscultation, Bilateral crepts were present and wheezing was noted.

CNS
The patient is conscious, drowsy.
Speech is normal.
No neck stiffness. Kernig's sign is absent.

Abdomen
Normal shape. No tenderness.
No palpable mass. Liver and spleen not palpable. 










Investigations


















Provisional diagnosis:
Acute exacerbation of COPD? , Acute kidney injury (AKI)? Renal failure? HF?

Treatment
Inj. LASIX 40 mg IV BD
Nebulization with Duolin and Budecort stat
Inj. Hydrocort 100 mg IV stat
Oxygen inhalation 10 liters
25% Dextrose IV stat
RBS monitoring (2 hourly)
Strict monitoring of SPO2, RR, PR, BP (3 hourly)
Syrup Ascoryl-LS 10 ml
Inj. Pantoprazole 40 mg IV 

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