58year old man with decreased urinary stream since 3days and anuria and pain abdomen for 1day

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's 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.

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box are welcome.

 Here is a case i have seen:

 A 58yr old male came with complaints of 

         Decreased urinary stream since 3days 

          not passing urine since 1 day

          Pain abdomen since 1day.

History of presenting illness:

       Patient was apparently asymptomatic 4days back then developed cough which was not associated with sputum followed by fever which was low grade,continuous,not associated with chills then developed dribbling of urine and decreased urinary output since 3 days associated with burning micturition.No hesitancy or urgency.

Past history:

K/c/o of Diabetes since 5yrs (metformin 500mg + glimiperide 1mg)

HTN since 8months (Tab.Amlong 5mg + Atenolol 50mg)

Cataract surgery left side and spine surgery 3yrs back.

Not a k/c/o asthma,elilepsy,ckd,cva.

Occasional alcoholic (2peeps whiskeys)

Not a known smoker

Vitals:

Bp:100/60

PR:76bpm regular in rythm and normal in volume

Temp:Afebrile

RR: 20/min

General Examination:

Patient was conscious,coherent,cooperative,moderately built n moderately nourished.

No pallor,icterus,cyanosis,clubbing,kilonychia,lymphadenopathy.

There is a grade 2 edema,non pitting,nontender.

Systemic examination:

CVS:S1,S2 heard.No murmurs

CNS:Intact

RS:NVBS heard,BAE +

P/A: soft,nontender .

Investigations:



Diagnosis:

Prerenal AKI with k/c/o of DM-2 and HTN

Treatment:

Inj.Piptaz 2.5mg/IV/TID

Inj.Pantop 40mgIV OD

Inj.Lasix 40mg IV BD

Inj.HAI S/C according to sliding scale

Tab.Amlong 5mg OD

Strict I/O charting

GRBS charting 6th hrly

Bp charting 2nd hrly

Temp & pulse rate charting 4th hrly





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