Case: 65 year old male with anuria

Neha Pradeep
MBBS 9th semester


Roll no: 99



This is 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 patients 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 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 diagnosis and treatment plan.

CASE:
65 year old male patient who is a toddy tree climber by occupation, came with the complaint of no urine output. 

History of Present Illness:
Patient developed anuria 2 days ago. Patient also complains of low grade fever with chills. Fever is sudden in onset, not progressive. Fever is continuous, and is relieved on medication. Patient complains of shortness of breath since one day, progressive from grade 2 to 3. Patient also has severe joint pains. 
Patient has complaints of urgency, hesitancy and incomplete voiding of urine. 
Patient has no complaints of swelling of lower limbs, orthopnea, PND, syncopal attacks , chest pain, palpitations, suprapubic pain, cough, cold, or vomiting.  

Past History:
20 years ago: Patient underwent surgical removal of renal stones. 
15 years ago:  While climbing a tree, he fell and fractured his right femur, and had a prosthesis placed. After this surgery, he has been using a cane to walk. 
10 years ago: He fell in the bathroom after which he has been unable to walk and been completely on bedrest. 

Patient has been hypertensive since 10 years, is regular with medication. 
No history of Diabetes, Asthma, Tuberculosis. 

Personal History:
Diet: Mixed 
Appetite: Decreased since two days
Sleep: Adequate
Bowel: Regular

Regular toddy drinker, more than 30 years. 
No known allergies. 

General Examination: 

Patient was conscious, coherent and mildly cooperative. Patient was moderately built and moderately nourished. 

No pallor, icterus, cyanosis, clubbing, generalized lymphadenopathy, and edema. 

Vitals: 
Blood Pressure: 130/80 mmHg
Respiratory Rate: 20 cycles per minute
Pulse: 80 bpm
Temperature: Afebrile

Fever Chart: 

Systemic Examination:

CVS: 
1) Inspection: 
- Chest wall is symmetrical
- No dilated veins, scars and sinuses. 
- No visible apical pulse 
- No visible pulsations
2) Palpation: 
- Apical Pulse: Normal in the 5th intercoastal space, 1cm lateral to the midclavicular line. 
- No palpable pulsations
3) Percussion
- Heart Borders can be percussed normally. 
4) Auscultation: 
- S1, S2 sounds are heard. 
- No abnormal heart sounds heard 

Respiratory System: 
1) Inspection: 
- Chest is symmetrical
- Trachea is in the midline 
- No drooping of shoulders
- No sinuses and dilated veins
2) Palpation: 
- Trachea – midline
- No dilated veins
- Chest movement is symmetrical
3) Percussion: 
                                      R         L 
Infraclavicular.      Resonant Resonant
Mammary              Resonant Resonant 
Axillary.                  Resonant Resonant
Infraaxillary           Resonant Resonant
Suprascapular      Resonant Resonant
Infrascapular        Resonant Resonant

4) Auscultation: 
-Infrascapular and infraaxillary areas: crepitations are heard bilaterally. 
-Breath sounds: Normal Vesicular Breath sounds
- No added breath sounds 

Abdominal Examination: 
1) Inspection: 
- Shape: scaphoid, not distended
- Flanks: free
- Umbilicus: midline, inverted
- Skin: not stretched, shiny, no scars, sinuses, striae
- No dilated veins
- No abnormal movements of the abdominal wall, visible peristalsis, 
2) Palpation: 
- No local rise in temperature, no tenderness 
- Soft on touch
3) Percussion: 
- No fluid thrill, shifting dullness
4) Auscultation: 
- Normal bowel sounds heard 

CNS: 
- Normal higher mental functions 
- No focal neurological deficit
- All higher motor functions are normal 
 
X-ray:

Clinical Pictures: 








Laboratory Investigations:
Blood Urea: 117 mg/dl

Serum Creatinine: 5.8 mg/dl 

Potassium: 5.4 mEq/L

Medication: 
Inj Ceftriaxone 1gm/iv/bd
Inj Lasix 40mg/iv
Inj Pan 40mg/iv/bd
Neb with Duolin and Budecort (8th hourly) 
Tab Amlong 5 mg

Comments

Post a Comment

Popular posts from this blog

INTERNSHIP ASSESSMENT

INTERNSHIP ASSESSMENT: Neha Pradeep Roll number: 110 My medicine posting during my internship year extended from 12th of April 2023 to the 12th of June 2023.  My time in medicine was divided into 4 parts, with 2 weeks each.  June 12th- June 28th : (UNIT)  I was placed in second unit. In this unit, Dr. Abhinaya, Dr. Narsimha, Dr. Prachethan and Dr. Harika were my SR and PGs. In duty, my main learnings came from time spent in OP, casualty and monitoring of admitted patients in unit.  Since we didn't have any admissions in unit for my first two weeks, most of my experience came from OP.  Here, we took history, examined the patient with respect to their presenting complaints. Here we learnt how to localize the problem without requiring excessive investigations and medicating without over treating.  On our first OP day, a case was brought to casualty in an unresponsive state, with seizure like activity.  Handling this case taught us a few basics of first line of treatment in emergency
Read more

BIMONTHY ASSESSMENT May 2021

Image
Neha Pradeep Roll no. 99 BIMONTHLY ASSESSMENT - MAY 2021 1) PULMONOLOGY: Case #1: https:// soumyanadella128eloggm. blogspot.com/2021/05/a-55- year-old-female-with- shortness-of.html   1) What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem? 20 years ago First SOB episode lasted one week. It was relieved on taking medication. 19-13 years ago Similar episodes, SOB lasted approximately one week.  All episodes were relieved upon taking medication. 12 years ago Episode of SOB, lasted 20 days. She was hospitalized. SOB decreased upon treatment at the hospital. 11-9 years ago SOB episode, lasting almost a month. 8 years ago Diagnosed with diabetes. Presented with polyuria. 7-5 years ago SOB episode lasted
Read more

Case: 80 year old man with lower back pain and breathlessness

Image
Neha Pradeep, MBBS 9th semester Roll no: 99 This is 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 patients 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 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 diagnosis and treatment plan. Case :  A 72 year old man, came with complaints of breathlessness and cough since 20 days and lower back pain since 10 days.  History of Presenting Illness:  A 80 year old
Read more