A 80 year old male with fever,SOB, decreased urine output

 

A 80 year old male from lingotam  came with C/C of 

• Pain in hypogastric region since 5 days

• Decreased urine output since 5 days

• Fever since 5 days

  • SOB on exertion since 3days

HISTORY OF PRESENT ILLNESS 


Patient was apparently asyptomatic 2 months back when he developed fever which was high grade, on and off ,a/w chills and rigors.

He also c/o decreased urine output since 5 days and pain in hypogastrium 

He also c/o SOB on exertion since 3days 

Went to nalgonda hospital but since the symptoms was not subsiding  he came here

No c/o cough, cold, headache



PAST HISTORY 


N/K/C/O   DM, HTN, Asthma, epilepsy, tb, CAD 


Treatment history 


Left kidney operated for stones in kmni hospital narketpally.

(Went to hospital because of flank pain.) 


FAMILY HISTORY 


Not relevant 


PERSONAL HISTORY 


Diet mixed 


Appetite decreased since 5 days 


B/B 

     Decreased urine output

     Bowel movements regular 


Sleep Disturbed since 5 days 


Addictions : Smokes chutta



DAILY ROUTINE 


Farmer by occupation previously but stopped working since 3 years because of body pains

Wakes up at 8 am

Drinks tea and watches TV

Lunch at 11 am

Sleeps and then wakes up up watches TV

Dinner at 7 pm

Sleeps by 9 pm 


GENERAL PHYSICAL EXAMINATION 


Patient is conscious coherent cooperative Well oriented to time place person Moderately built and nourished 


Pallor  present 


Icterus absent 


Cyanosis absent 


Clubbing absent 


Lymphadenopathy absent 


Edema absent 


Vitals 


On 26/8/22

Temperature : 98.2°f


PR :  96 bpm


RR : 20 cpm


BP : 120/80 mmHg


SPO2 :  98 % at RA 


GRBS  : 139


On 27/8/22

Temperature  98.2°f


PR 96 bpm


RR 20 cpm


BP 130/70 mmHg


SYSTEMIC EXAMINATION 


CVS- S1 S2 heard, no murmurs 


CNS- NFD 


RS- BAE ,NVBS 


PA- Soft and  tender 



CLINICAL IMAGES and INVESTIGATIONS 












PROVISIONAL DIAGNOSIS 


Urinary tract infection with Acute kidney injury with hyponatremia(Euvolemic) with Iron deficiency anemia 



TREATMENT 


IV fluids :NS,RL

Inj Monocef 1 gm /iv/BD

Inj optineuron 1 amp in 100 ml NS/IV/OD

Inj ZOFER 4 mg /IV/SOS

TAB RANTAL 150mg/BD

Protein x powder  1 scoop in 100ml milk TD

BP/PR/TEMP monitoring

Inj Iron sucrose 200mg in 100ml NS 

Inj Iron sucrose 200mg in 100ml NS 

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