80 yr old male with uremic encephalopathy,post renal AKI secondary to Bladder outlet obstruction (?vesical calculus)
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A 80 year old male patient,resident of chityal,farmer by occupation presented to causality with chief complaints of burning micturition since 15 days,fever since 5 days
decreased urine output since 4 days,
shortness of breath since 4 days,Hematuria since 3 days.
History of present illness:
Patient was apparently normal 8 years back then he had abdominal pain which was associated with fever and vomitings and diagnosed with ? Liver abscess and needle aspiration was done.
4 years back patient developed a blister over right ankle which ruptured and for ulcer and cellulitis debridement was done.
Since 15 days patient had c/o burning micturition associated with fever, nausea, vomitings and treated accordingly. Fever since 4-5 days, intermittent,not associated with chills .Hematuria since 3 days.Decreased urine output and shortness of breath since 4 days .
He underwent 4 sessions of dialysis on 15th dec ,16th dec,18th dec and 20th dec
Past history:-
Not a known case of diabetes, hypertension, tuberculosis, epilepsy, asthma.
Personal history:-
Patient has normal eating habit with mixed diet.
Not an alcoholic, not a smoker.
Loss of apetite.
Routine before 15 days back:-
Patient used to wake up at 5 or 5:30 am ,he used to fresh up and drink milk and he used to do dairy work.Then he used to look up at his farm and he used to eat 3 times a day and he was normal.
Routine from 15 days:-
Patient used to wake up at 5 or 5 :30,he used to dairy work but he was having weakness and he was not eating properly as before.From past 5 days he was even unable to walk staying at home only.
Family history:-
No significant family history.
General examination :-
Patient is conscious,oriented to person,not to time and place.
No pallor
No icterus
No clubbing
No lymphadenopathy
No edema
Vitals :-
Temperature-99f
Pulse rate- 104bpm
Respiratory rate- 20cpm
BP -90/70mmhg
Spo2- 98% with 4lit o2
Systemic Examination :
CVS : S1S2 + , No murmurs.
RS : BAE + .
P/A : Soft , Nontender.
CNS : HMF intact.
Provisional diagnosis:-
Urosepsis post renal AKI secondary to bladder outlet obstruction B/l moderate hydroureteronephrosis
Vesical calculus
Uremic encephalopathy
Prostatomegaly Grade 1
Investigations:-
Treatment:-
Inj meropenem 500mg iv bd
Inj pan 40 mg iv od
Iv fluids 0.45 NS @ u.o.+30ml/hr
Tab pcm 650mg RT SOS
RT feeds free water,milk with protein powder 4th hrly
Monitor vitals
I/o charting
