CASE DISCUSSION :
A 84 year male patient presented to OPD with C/C of fever since 2 months
Shortness of breath since 1 month
Decreased urine output since 1 month
Pain abdomen since 2days
HOPI :
Patient was apparently asymptomatic
2 months back then he developed fever which is intermittent type, low grade fever associated with chills, body pains, loss of appetite since 3days.
H/o dyspnea since 1month..which is insidious in onset aggrevated while walking, doing daily activities and relieved on lying down.No posturnal and diurnal variations
Decreased urine output since 1 month. burning sensation while micturition
He has h/o pain abdomen since 2days, which is diffuse, cramping type.
He has no h/o headache, vomiting, cough, dysuria, diarrhea, constipation, palpitations ,pedal edema .
PAST HISTORY:
No similar complaints in past
Known case of HTN: 7 years and on medication telma40mg and amlog 5mg
Know case of CKD : 1year
H/o ORIF surgery on Right knee 2yrs back
PERSONAL HISTORY:
Diet :mixed
Sleep :adequate
Appetite :decreased
Bowel: regular
Addictions: alcoholic, toddy ocassionally
Smokes beedies 1pack/day.
Not allergic to any drugs
PHYSICAL EXAMINATION:
Patient is conscious, coherent, cooperative, moderately built.
No pallor, icterus, clubbing,cyanosis ,pedaledema,lympadenopathy.
Vitals: bp-100/80mmhg
PR-74bpm
RR-24cpm
Temp- 97.1F
SYSTEMIC EXAMINATION:
Respiratory system : trachea central
Normal Vesicular breath sounds heard. B/l air entry present.
Dyspnoea
No wheeze, no added sounds.
Per abdomen:
Shape of abdomen: scaphoid
No tenderness present
No organomegaly
Bowel sounds heard
CVS:
S1,S2 heard
No murmurs
CNS:patient is conscious
Speech normal
Cranial nerves intact
Sensory system normal
Motar system normal
No signs of meningeal irritation
INVESTIGATIONS:
Hemogram
RFT:
CUE:
ECG:
USG OF ABDOMEN:
LFT:
URINE CULTURE:
MALARIA PARASITE STRIP TEST:
ESR:
DIAGNOSIS:
URINARY TRACT INFECTION WITH CKD STAGE 4
TREATMENT:
Inj.pantop 40mg iv OD
Inj. Zofer 4mg iv SOS
Tab. Ciprofloxacin 500mg BD
Tab. Nodosis 500mg p/o TID
Inj. Buslopan 2cc im OD
IVF 20 NS at 50 ml/hr
Inj.thiamine 1 amp in 100 ml NS OD
Inj. Optineuron 1 amp in 100 ml NS OD
Tab. PCM 650 mg P/o SOP
