A 67 year old male with C/O decreased urine output, burning micturition and lethargy since 15 days.
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A 67 year old male, weaver by occupation came to causality with C/O decreased urine output, burning micturition and lethargy since 15 days.
HOPI:
Patient was apparently alright one year back then he started experiencing altered sleep cycle, he was also experiencing episodes of polyuria and nocturia in this one year. 15 days back he had 2 episodes of vomitings, 4-5 episodes of loose stools, had burning sensation in the tongue and throat so that he was taking only minimal water and milk. Patient had decreased urine output and whenever he tried to micturate associated with burning sensation in the penis, which lasted for 20mins. Because of this symptom (dysuria) he totally decreased intake of fluids so that he won't get painful urination. Whenever he passes urine, it totally amounts to 10ml. Patient had c/o poor stream of urine and urinary incontinence since 1 year. Patient had recurrent episodes of UTI (in the past 1 year). Because of his urinary incontinence, patient totally avoided social gatherings in the past 1 year.10 days back he experienced dysphagia for which he was hospitalised and was Managed for the same. He had two episode of vomiting non-bilious, non-projectile, containing food particles. He had 4-5 episodes of loose tools per day.
History of fever on and off
No history of dyspnoea SOB palpitations chest pain PND
No history of abdominal pain, distension.
History of burning micturition present, H/O pyuria present.
Past history:
N/A/K/O HTN, DM, HYPOTHYROIDISM, CVA, EPILEPSY
H/O cataract surgery 2 months back.
FAMILY HISTORY:
No significant family history.
GENERAL EXAMINATION:
O/E : Patient is C/C/C
Clubbing - present
Pallor - present
Icterus absent
Cyanosis - absent
Edema of feet - absent
Lymphadenopathy - absent
VITALS:-
BP: 100/70mmhg
PR: 96 bpm
RR: 20cpm
Spo2: 97%
GRBS: 79 mg/do
SYSTEMIC EXAMINATION :
CARDIOVASCULAR SYSTEM : S1 and S2 heard, no murmurs heard
RESPIRATORY SYSTEM : BAE present, NVBS heard.
P/A : soft, non tender
CNS: NAD
Clinical images:
12/12/2020
Hb- 13.6
Total counts- 5,700
Platelets- 3.5 lakhs
Rbs-114
13/12/2020
S. Creat-3.6
CUE:
Pus cells- plenty
RBC- nil
EC- 2-3
ultrasound done on 20/12/2019
Ultrasound done on 18/10/21
Investigations:
22/3/22
S.urea- 203
S.creat-8.4
Abg:
PH- 7.13
PCO2- 5.6
PO2- 135
HCO3- 1.8
23/3/22
S.urea-190
S.creat-8.3
Abg:
PH- 7.17
PCO2- 8.6
PO2- 138
HCO3- 3.1
24/3/22
S.urea- 136
S.creat- 6.2
Abg:
PH- 7.2
PCO2- 8.8
SO2- 96.1
HCO3- 3.5
Ultrasound done on 22/3/22
Recurrent UTI secondary to ?Renal calculi
AKI ON CKD
metabolic acidosis
NC NC anemia(2o to CKD)
TREATMENT:
1. IVF NS & RL @100ml/hr
2. Inj. Monocef 1gm/po/nd
3. Inj. Pan 40 mg/iv/of
4. Mucopain gel oinent for L/A
5. GRBS 6th hourly
6. Vitals monitoring 4th hourly
Soap notes:
23/3/22
Day 1
ICU bed no 3
S:
C/O decreased urine output, burning micturition and lethargy since 15 days.
O:
O/E:
Patient is conscious, coherent and cooperative.
Clubbing present
Pallor present
No icterus/cyanosis/generalized lymphadenopathy/pedal oedema
Temp: afebrile
BP: 100/70 mmhg
PR: 82bpm
CVS: S1S2 +, no murmurs
RS: BAE +, NVBS heard
P/A: soft and Non tender
S.urea-190
S.creat-8.3
Abg:
PH- 7.17
PCO2- 8.6
PO2- 138
HCO3- 3.1
A:
Recurrent UTI secondary to ?Renal calculi
AKI ON CKD
metabolic acidosis
NC NC anemia(2o to CKD)
P:
1. IVF NS & RL @100ml/hr
2. Inj. Monocef 1gm/po/nd
3. Inj. Pan 40 mg/iv/of
4. Mucopain gel oinent for L/A
5. GRBS 6th hourly
6. Vitals monitoring 4th hourly
24/3/22
Day-2
ICU bed no.3
S:
- Decreased urine output
- Burning micturition reduced
- Lethargy subsided
- No fever spikes
O:
O/E:
Patient is conscious, coherent and cooperative.
Clubbing present
Pallor present
No icterus/cyanosis/generalized lymphadenopathy/pedal oedema
Temp: afebrile
BP: 100/70 mmhg (NORAD-7ml/hr)
PR: 74bpm
CVS: S1S2 +, no murmurs
RS: BAE +, NVBS heard
P/A: soft and Non tender
S.urea- 136
S.creat- 6.2
Abg:
PH- 7.2
PCO2- 8.8
HCO3- 3.5
Input-1800ml
Output-750ml
A:
Recurrent UTI secondary to ?Renal calculi
AKI ON CKD
metabolic acidosis
NC NC anemia(2o to CKD)
P:
1. IVF NS & RL @100ml/hr
2. Inj. Monocef 1gm/po/nd (DAY-2)
3. Inj. Pan 40 mg/iv/of
4. Mucopain gel oinent for L/A
5. Inj. NORAD 2amp in 46ml NS @ 6ml/hr
6. Inj. Optineuro 1amp/od
7. GRBS 6th hourly
8. Vitals monitoring 4th hourly
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