64M with loss of appetite and decreased urine output.

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient' problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

A 64 year old male daily waged labourer by occupation presented to casuality with cheif complaints of : 

1. Decrease urine output since 1 month

2. Loss of appetite since 1 month.

3. Abdominal discomfort and constipation on and off since 1 month.

Patient was apparently alright 10years back then he had a episode of giddiness followed by fall when he was coming out from washroom, following which he visited nearest RMP who referred him for higher center for further evaluation and management.

Then he went to a private hospital in Hyderabad where he was told to have both renal failure and low hemoglobin and hypertension then he was transfused with 1 unit of blood. Since then he was on conservative management for renal failure.

Now he presented with complaints of decreased urine output, loss of appetite and abdominal discomfort associated with constipation on and off and nausea. Knee joint pains, neck pains and low back ache.

K/C/O HTN since 10 years 

Personal history :

Appetite : decreased 

Diet : mixed 

Sleep : adequate 

Bladder : decreased urine output

Bowel movements: regular 

Addictions : occasional alcoholic and smoker 

 

General examination:

Pallor: present 

Icterus: absent

Cyanosis : absent 

Clubbing : present

Lymphadenopathy : absent 

Edema : present B/L pitting type of pedal edema

Vitals:

 Temperature: afebrile 

 Pulse: 89 bpm

 Blood pressure:130/80 mm of hg

 Respiratory rate : 20 bpm

SpO2 : 98 on RA

GRBS : 138 MG/DL

Systemic examination:

Cardiovascular system  

JVP - Not raised 

Visible pulsations: absent 

Apical impulse : left 5th intercostal space in midclavicular line.

Thrills -absent 

S1, S2 - heart sounds heard 

Pericardial rub - absent

Respiratory system:

Patient examined in sitting position

Inspection:-

oral cavity- Normal ,nose- normal ,pharynx-normal 

Shape of chest - normal

Chest movements : bilaterally symmetrical 

Trachea is central in position.

Palpation:-

All inspiratory findings are confirmed

Trachea central in position

Apical impulse in left 5th ICS, 

AUSCULTATION 

B/L IAA crepts present.

Abdomen examination:

INSPECTION

Shape : distended 

Umbilicus:normal 

Movements :normal

Visible pulsations :absent

Skin or surface of the abdomen : normal 

PERCUSSION- tympanic

AUSCULTATION :bowel sounds heard

USG : 

Labs : 

Diagnosis: 

CHRONIC RENAL FAILURE WITH HYPERTENSION.

Treatment : 

1. Hemodialysis initiated on 17/06/22

2. Salt and fluid restrictions 

3. T. Lasix 4o mg BD

4. T. Cilacar 10mg OD

5. T NODOSIS 500mg BD

6. T. Orofer-XT OD

7. T. Shelcal 500mg PO OD

8. Monitor vital

Post central line xray : 

Xray C spine and LS spine : 

X ray foot :