A 80 year old male patient with uraemic encephalopathy
80 YEAR OLD MALE PATIENT PRESENTED WITH DECREASED URINE OUTPUT
December 20, 2021
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Date of admission:13/12/2021
CHIEF COMPLAINTS:
A 80 year old male resident of nalgonda, farmer by occupation came to OPD with chief complaints of decreased urine output with burning micturition since 15 days.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 15days back. He then gradually developed burning micturition ,body pains and low grade fever which was insidious in onset, intermittent, associated with chills and rigors and relieved on medication.
He also had gradual decrease in urine output since 15 days, for which he consulted nearby rmp after 2 days and catheter was inserted. He also developed bilateral pedal edema which is of pitting type.
He also had history of grade - 4 SOB and altered sensorium since 7days.
Blood in urine 7days back.
Clenching of teeth since morning.
Patient has swelling in right inguinal region.
Patient is on Ryle's tube since 10 days.
No h/o loose stools, abdominal pain.
Past history:
Similar complaints of bilateral pedal edema,facial puffiness and skin color changed to black 8 years back and diagnosed with liver abscess and needle aspiration was done and was treated accordingly.
5 years back, patient developed a blister in right ankle region which ruptured and an ulcer was formed. Treatment included ayurvedic medication. Ulcer healed after 2 years.
No HTN,DM,epilepsy,TB,asthma,CAD.
Personal history:
Diet: vegetarian
Appetite: decreased
Sleep: Inadequate sleep due to body pains
Micturition: decreased with burning sensation.
Bowel movements: Regular
Addictions:No
Family history:
Patient wife also died because of chronic kidney injury
TREATMENT HISTORY:
No relevant treatment history
General examination:
Patient is conscious, oriented to person, not to time and place.
Thin built.
Pallor present
No icterus
No clubbing
No lymphadenopathy
B/L pedal edema
Vitals:
Temp : Afebrile
BP : 110/70 mm Hg
PR : 104bpm
RR : 20 cpm
GRBS : 120 mg / dl
SpO2 : 98 % @ RA
Systemic examination:
CNS : E3 V5 M5
CVS : S1 & S2 heard, No murmurs
RS : BAE present, VBS heard
P/A : Soft , Nontender , BS +
Investigations:
X-ray
USG
ECG
14/12/2021
ABG:14/12/2021
16/12/2021
Hemogram:
14/12/21 16/12/21
Hb - 10.2 gm/dl. 9.1gm/dl
TLC - 21,400 cells/cumm 22,800 cells/ cumm
Neutrophils - 89% 85%
PCV - 25.4% 30%
RBC count - 3.18 3.57
Lymphocytes - 2% 4%
RFT:
14/12/21 16/12/21
Urea - 364mg/dl 215mg/dl
Creatinine - 9.1mg/dl 5.4mg/dl
Uric acid -11.7mg/dl 6.6mg/dl
Phosphorus - 6.6mg/dl 5.6mg/dl
Na -148mEq/L 151mEq/L
K - 6.8mEq/L 4.4mEq/L
Provisional diagnosis:
URAEMIC ENCEPHALOPATHY (resolving)
POST RENAL AKI SECONDARY TO BLADDER OUTLET OBSTRUCTION
PROSTATOMEGALY GRADE 1
B/L MODERATE HYDROURETERONEPHROSIS
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
On 18/12/2021:
On 20/12/2021:
Inj meropenem 500mg iv bd d3
Inj pan 40 mg iv od
Iv fluids 0.45 NS @ u.o.+30ml/hr
Tab pcm 650mg RT SOS
RT feeds free water,milk with protein powder 4th hrly
Fever chart-21/12/2021
No fever spikes since yesterday
☆ 4 sessions of Hemodialysis done since 13/12/2021
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