65 year old male with decreased urine output and giddiness

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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