65 year old male with decreased urine output and giddiness


This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
A 65 year old male resident of Choutuppal, Potter by occupation came to casualty with 
decreased output and giddiness since 3 days and
vomitings since 2 days 
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 6 years back and then he developed body pains for which he went to local RMP and was on painkillers since then.
3 years ago on regular check up he was diagnosed with hypertension and is on medication since then.
1 year ago patient was diagnosed with diabetes mellitus and was on regular medication since then.
3 days ago the patient complains of decreased urine output, associated with burning micturition.
No history of fever, hematuria, pyuria.
Vomitings since 2 days 3 episodes per day, associated with nausea, non projectile, non bilious, food as contents and no blood.
PAST HISTORY:
He is a known case of Hypertension since 3 years for which he is taking MET XL 50mg ( Metoprolol) OD
Diabetes since 1 year for which he is taking Metformin+ Tenegliptin 
No history of asthma, cardiovascular accidents, epilepsy.
PERSONAL HISTORY:
DIET:Mixed
APPETITE: decreased since last 4 days
SLEEP: Adequate 
BOWEL AND BLADDER MOVEMENTS: burning micturition
ADDICTIONS: No Addictions
FAMILY HISTORY: Not significant
GENERAL EXAMINATION:
Patient was conscious,coherent and cooperative,well oriented to time,place and person.
Pallor is present
Icterus, cyanosis, clubbing, lymphadenopathy and edema are absent.
VITALS:
Temperature 97.4F
Pulse rate 101 BPM
Respiratory rate 16cpm
Blood pressure 120/80 mmHg
SpO2 96%
GBRS 102mg%
SYSTEMIC EXAMINATION:
CVS : 
On palpation ‐
• Apex beat was felt in the left 5th intercostal space medial to the mid clavicular line on left side.
• JVP was normal 
• No precordial bulge 
• No parasternal heave
On auscultation ‐ S1, S2 heard , no murmurs 
RS :
On inspection ‐
• Chest is bilaterally symmetrical 
• Expansion of chest: Equal on both sides
• Position of trachea: Central
• No visible scars, sinuses, pulsations
On palpation : 
• Expansion of chest was equal on both sides. 
• Position of trachea: Central
• Tactile Vocal Fremitus: resonant note was felt.
On percussion: all lung areas were resonant 
On auscultation : 
• Bilateral air entry was present, normal vesicular breath sounds were heard. 
• Vocal resonance: resonant in all areas
P/A : soft, non tender, no organomegaly, no distension, bowel sounds heard.
CNS : The patient is well oriented to time, place, person.
Higher mental functions are intact.
Cranial nerve examination :‐
All cranial nerves are intact and functioning. 
Motor System Examination :‐
• Normal bulk in upper and lower limbs
• Normal tone in upper and lower limbs
• Normal power in upper and lower limbs
• Gait is normal 
. Reflexes are normal .
Sensory System Examination :‐
Normal sensations are felt in all the dermatomes.
No cerebellar signs .
No meningeal signs.
INVESTIGATIONS:
Hemogram 
LFT
RFT
USG ABDOMEN 
PROVISIONAL DIAGNOSIS:
Chronic kidney disease (? NSAID abuse) with hypertension since 3 years and diabetes since 1 year.

TREATMENT:
Inj. Lasix 40mg
Inj. HAI according to GRBS
Inj.Zofer 4mg IV 
Tab.Nicardia 10mg
Tab.MetXL 50mg
Tab.Nodosis 500mg
Tab.BioD3 
Tab.Shelcal 500mg
Tab.Orofer
Tab.Levocetrizine 1 tab
Inj.Monocef 1gm

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