80 YEAR OLD MALE WITH UREMIC ENCEPHALOPATHY, AKI SECONDARY TO BOO(? vesical calculus)

-

 December 14, 2021

Patient came to casualty with
 c/o burning micturition since 15 days
 fever since 5 days 
decreased urine output since 4 days, 
sob since 4 days
Hematuria + for 3 days

HOPI :  Patient was apparently normal 8 years back then he had pain abdomen a/w fever and vomitings and diagnosed with ? Liver abscess and needle aspiration was done.
4 years back patient developed a blister over right ankle which ruptured and for ulcer and cellulitis debridement was done. Since 15 days patient had c/o burning micturition associated with fever, nausea, vomitings and treated accordingly. Fever since 4-5 days, intermittent,not a/w chills and rigors.no loose stools
PAST HISTORY : No HTN/DM
                        NON ALCOHOLIC/NON SMOKER

General examination :

Pt is conscious,coherent and cooperative.thin built and malnourished.

No pallor
No icterus
No clubbing
No lymphadenopathy
No edema
 
Vitals :

Temp : Afebrile
BP : 170/90 mm Hg
PR : 118 bpm
RR : 16 cpm
GRBS : 114 mg / dl
SpO2 : 98 % @ RA

Systemic Examination :
CVS : S1S2 + , No murmurs
RS : BAE + , NVBS +
P/A : Soft , Nontender , BS +
CNS : HMF intact

Provisional diagnosis : 

URAEMIC ENCEPHALOPATHY 
POST RENAL AKI SECONDARY TO BOO(? VESICAL CALCULUS)
? CHRONIC CYSTITIS/? PYELONEPHRITIS
PROSTATOMEGALY GRADE 1

Clinical images :



Plan of treatment :
INJ.PCM 1 GM /IV/SOS
INJ.PAN 40MG/IV/SOS
INJ.ZOFER 4MG/IV/TID
IVF NS@UO+30ML/HR
TAB.NICARDIA 10 MG/PO/STAT
BP/PR/TEMP MONITORING 4TH HOURLY
TAB. NODOSIN 500MG/PO/ TID
INJ.PIPTAZ 4.5GM/IV/STAT


                              DAY 2:
S-FEVER WITH CHILLS

O- O/E pt AROUSABLE
*BP-100/60 mm of hg on NA @ 20 ml/hr 
*PR-120 bpm
*spo2-93% 
*cvs-s1,s2 +
*RS-BAE + 
*P/A - soft and non tender 
*CNS-B/L pupils NSRL
E4V15M6


A- UROSEPSIS SEPSIS SECONDARY TO POST RENAL OBSTRUCTION 
POST RENAL AKI SECONDARY TO ? B.O.O
B/L MODERATE HYDROURETERONEPHROIS
VESICLE CALCULUS (5MM)
UREMIC ENCEPHALOPATHY 

1]INJ. MEROPENEM 500mg/IV/BD
      2]INJ.PAN 40
      3]INJ. ZOFER
      4]IVF 1NS , 1RL @50 ML/MIN 
      5]INJ. LASIX 20 
      6]TAB PCM 650 
      7]TAB NODOSIS  500
      8]BP,PR,TEMP MONITORING
      9]RT FEEDS [free water milk + protein 100 ml 4th hourly 
      10]STRICT I/O CHARTING 
      11]INJ. NORADRENALINE @ 14ML/HR 


                                     DAY 3:

S- C/O DRYNESS OF TONGUE


O- O/E pt AROUSABLE
*BP-100/60 mm of hg on NA @ 20 ml/hr 
*PR-120 bpm
*spo2-93% 
*cvs-s1,s2 +
*RS-BAE + 
*P/A - soft and non tender 
*CNS-B/L pupils NSRL
E4V15M6


A- UROSEPSIS SEPSIS SECONDARY TO POST RENAL OBSTRUCTION 
POST RENAL AKI SECONDARY TO ? B.O.O
B/L MODERATE HYDROURETERONEPHROIS
VESICLE CALCULUS (5MM)
UREMIC ENCEPHALOPATHY 

1]INJ. MEROPENEM 500mg/IV/BD
      2]INJ.PAN 40
      3]INJ. ZOFER
      4]IVF 1NS , 1RL @50 ML/MIN 
      5]INJ. LASIX 20 
      6]TAB PCM 650 
      7]TAB NODOSIS  500
      8]BP,PR,TEMP MONITORING
      9]RT FEEDS [free water milk + protein 100 ml 4th hourly 
      10]STRICT I/O CHARTING 
      11]INJ. NORADRENALINE @ 14ML/HR 


                                         DAY 4  :

O- O/E pt concious 
*BP-80/40 mm of hg on NA @ 20 ml/hr 
*PR-120 bpm
*spo2-93% 
*cvs-s1,s2 +
*RS-BAE + 
*P/A - soft and non tender 
*CNS-B/L pupils NSRL
E4V15M6


A- UROSEPSIS SEPSIS SECONDARY TO POST RENAL OBSTRUCTION 
POST RENAL AKI SECONDARY TO ? B.O.O
B/L MODERATE HYDROURETERONEPHROIS
VESICLE CALCULUS (5MM)
UREMIC ENCEPHALOPATHY 
2 SESSIONS OF DIALYSIS DONE 



P-
      8]BP,PR,TEMP MONITORING
      9]RT FEEDS [free water milk + protein 100 ml 4th hourly 
      10]STRICT I/O CHARTING 
      11]INJ. NORADRENALINE @ 14ML/HR 
      12]INJ DOBUTAMINE @ 10 ML /HR 
  1]INJ. PIPTAZ 45mg/IV/BD
      2]INJ.PAN 40
      3]INJ. ZOFER
      4]INJ OPTINEURON LAMP IN 100 ML / IV / OD 
      5]INJ. LASIX 20 
      6]TAB PCM 650 
      7]TAB NODOSIS  500
                                       DAY 5:

O- O/E pt drowsy but arousable 
*BP-60/40 mm of hg on NA @ 20 ml/hr 
*PR-120 bpm
*spo2-93% 
*cvs-s1,s2 +
*RS-BAE + 
*P/A - soft and non tender 
*CNS-B/L pupils NSRL
E4V15M6


A- UROSEPSIS SEPSIS SECONDARY TO POST RENAL OBSTRUCTION 
POST RENAL AKI SECONDARY TO ? B.O.O
B/L MODERATE HYDROURETERONEPHROIS
VESICLE CALCULUS (5MM)
UREMIC ENCEPHALOPATHY 
2 SESSIONS OF DIALYSIS DONE 



P-  1]INJ. MEROPENEM 500mg/IV/BD
      2]INJ.PAN 40
      3]INJ. ZOFER
      4]IVF 1NS , 1RL @50 ML/MIN 
      5]INJ. LASIX 20 
      6]TAB PCM 650 
      7]TAB NODOSIS  500
      8]BP,PR,TEMP MONITORING
      9]RT FEEDS [free water milk + protein 100 ml 4th hourly 
      10]STRICT I/O CHARTING 
      11]INJ. NORADRENALINE @ 14ML/HR 

                                     DAY 6 :
S- 


O- O/E pt concious 
*BP-80/60 mm of hg on NA @ 20 ml/hr 
*PR-120 bpm
*spo2-93% 
*cvs-s1,s2 +
*RS-BAE + 
*P/A - soft and non tender 
*CNS-B/L pupils NSRL
E4V15M6


A- UROSEPSIS SEPSIS SECONDARY TO POST RENAL OBSTRUCTION 
POST RENAL AKI SECONDARY TO ? B.O.O
B/L MODERATE HYDROURETERONEPHROIS
VESICLE CALCULUS (5MM)
UREMIC ENCEPHALOPATHY 
3 SESSIONS OF DIALYSIS DONE 



P-  1]INJ. MEROPENEM 500mg/IV/BD
      2]INJ.PAN 40
      3]INJ. ZOFER
      4]IVF 1NS , 1RL @50 ML/MIN 
      5]INJ. LASIX 20 
      6]TAB PCM 650 
      7]TAB NODOSIS  500
      8]BP,PR,TEMP MONITORING
      9]RT FEEDS [free water milk + protein 100 ml 4th hourly 
      10]STRICT I/O CHARTING 
      11]INJ. NORADRENALINE @ 14ML/HR 
      12]INJ DOBUTAMINE @ 10 ml/hr 





                                  DAY 7:
S- NO FEVER SPIKES SINCE YESTERDAY


O- O/E pt concious  but irritable 
*BP-110/70 mm of hg on NA @ 20 ml/hr 
*PR-120 bpm
*spo2-93% 
*cvs-s1,s2 +
*RS-BAE + 
*P/A - soft and non tender 
*CNS-B/L pupils NSRL
E4V15M6


A- UROSEPSIS SEPSIS SECONDARY TO POST RENAL OBSTRUCTION 
POST RENAL AKI SECONDARY TO ? B.O.O
B/L MODERATE HYDROURETERONEPHROIS
VESICLE CALCULUS (5MM)
UREMIC ENCEPHALOPATHY 
4 SESSIONS OF DIALYSIS DONE 



P-  1]INJ. MEROPENEM 500mg/IV/BD
      2]INJ.PAN 40
      3]INJ. ZOFER
      4]IVF 1NS , 1RL @50 ML/MIN 
      5]INJ. LASIX 20 
      6]TAB PCM 650 
      7]TAB NODOSIS  500
      8]BP,PR,TEMP MONITORING
      9]RT FEEDS [free water milk + protein 100 ml 4th hourly 
      10]STRICT I/O CHARTING 
      11]INJ. NORADRENALINE @ 14ML/HR 
      12]INJ DOBUTAMINE @ 10 ML /HR 

                                  DAY 8 :
patient's attenders were not willing to have further treatment inspite of explaing the needs of further investigations and they left against medical advice [LAMA]


Comments

Post a Comment

Popular posts from this blog

30f with osteomalacia??

-
Image
A 30yr Old Female with ? Osteomalacia This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome 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 a diagnosis and treatment plan CASE A 30yr old female, Daily wage Labourer by occupation came to OPD with cheif complaints of Pain in B/L Lower limbs since 2 years.  Patient wa
Read more

83 MOHAMMED WAHAAJ BIMONTHLY ASSIGNMENT

-
 BIMONTHLY  ASSIGNMENT (August)   BELOW IS THE LINK TO THE QUESTIONS ASKED TO US:- http://medicinedepartment.blogspot.com/2021/08/medicine-paper-for-aug-2021-bimonthly.html QUESTION 1:- Below is the link of the student for which I am giving my peer review. https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006003-case-presentations.html?m=1 LONG CASE  :- A 44 year old man presented with a 3-day history of bilaterally symmetrical rapidly progressive generalized edema. REVIEW:- The Case is well presented and  p atient data has be deidentified and privacy is marked. C ase history is taken beautifully precisely taken including social ,educational and surgical  history which is way too essential to understand the socio economic back ground of the patient and helpful in accurate diagnosis. FINAL DIAGNOSIS : - Acute Glomerulonephritis, likely due to Secondary Amyloidosis due to Chronic Poorly Treated Seronegative Erosive Rheumatoid Arthritis. Dilutional Hyponatremia secondary to A
Read more

RIGHT HEART FAILURE SECONDARY TO COPD

-
Image
  under the guidance of Dr. Rishik (Intern) This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission. I have 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 a diagnosis and treatment plan. CASE SCENARIO: A 52yr old patient came to the ward on 29 June 2021 with chief complaints of  right lower limb swelling, intermittent fever (alive and well), shortness of breath  since 3days, and  burning micturition  for 15 days. HISTORY OF PRESENTING ILLNESS The patient was asymptomatic 5days ago, after which he developed right lower limb swelling up to the knee. No H/O trauma, thorn prick, nausea, vomiting c/o a small wound, watery discharge since 2 days Fever- 5days intermittent, low grade, a/w chill A light rise in temp sob on exertion -5days a/w cough- 1
Read more