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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