75 yr Male with anuria

THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT .

CHEIF COMPLAINTS: 

 Drowsy ; Anuria ( since 3 days ) ; generalized weakness (since 15 days ) 

HISTORY OF PRESENTING ILLNESS : 
Patient was apparently asymptomatic 5 years back then he developed lower back pain then treated conservatively . But since 15 days pt developed generalized weaknesses while working in the farm.
Then 3 days back patient developed anuria.

H/O PAST ILLNESS:-
No similar complaints of anuria in the past. But had complaints of generalized weakness since 2 years.

PERSONAL HISTORY:-
Diet:- Mixed
Appetite:- Normal
Bowel movements:- Normal
Bladder:- Decreased urine output
ADICTIONS:-
Alcohol:- 90ml /day since he was 18 years old but stopped 1 year back
Tobacco:-1 pack beedi/day since he was 18 years old but stopped 1 year back.

FAMILY HISTORY:-
Not significant.

TREATMENT HISTORY:-

GENERAL EXAMINATION:-

Patient is examined in a well lit room after obtaining consent
•Patient is conscious, coherent, cooperative.
 •Well built and well nourished.
• pallor and edema present.
•Icterus,clubbing, cyanosis, koilonychia are absent



•VITALS 
Temp- Afebrile 

Bp-150/90 mm hg

PR- 96bpm

RR-24CPM

Spo2- 96% on RA

GRBS : 315 mg/ dl

SYSTEMIC EXAMINATION :

RS- bilateral air entry present 

CVS : S1, S2 + no murmurs 

P/A- soft and non tender
      
bowel sounds present 

CNS : No focal neurological defeicit 
HMF intact 
Power in B/L upper and lower limb Is 5
Reflexes are present with B/L plantars and flexors

INVESTIGATIONS:-
















 

PROVISIONAL DIAGNOSIS:-

Acute kidney injury (AKI ) 

MANAGEMENT:-

Salt restriction < 2g / day 
IVF NS 50 ml/ hr 
INJ : LASIK 40 mg stat 
INJ : PIPTAZ 4.5 g stat 
INJ : NEOMOL
O2 supplementation to maintain saturations >85%
Monitor Vitals BP PR TEMP hourly 
Strict IO charting 
Inform SOS 







 


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  THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT . This E blog also reflects my patient-centered online learning portfolio and your valuable input in the comment box are welcome. 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, and investigations, and coming up with diagnosis and treatment plan The patient/attender was informed of the purpose of the information being acquired. Informed consent was taken from the patient/attender and there is the omission of information that was r
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