80 year old male with oliguria

 Final exam case report - long case 

NAME: K.Lasya Mithra 

HALLTICKET NO - 1701006070

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CASE:

A 80 year old male patient presented to hospital with 

Chief complaints:

Fever - 2 days

Decreased urine output- 1 day

History of present illness :

Patient was apparently asymptomatic 10 years back then he developed fever which is insidious in onset , gradually progressive, continuous ,not  relieved on medication and  associated with chills and rigors  and decreased urine output for  which he visited local hospital and was diagnosed with acute renal failure and had two sessions of dialysis. From then he was on medication with diuretics(Tab.Furosemide) .He was diagnosed with hypertension and is on regular medication .

From then he had recurrent episodes 2-3 episodes/year for which he was treated at local hospital symptomatically. 

Presently he developed fever  from 2 days which is insidious in onset , gradually progressive, continuous, relieved on medication and  associated with chills and rigors. It is not associated with cough , cold , shortness of breath, night sweats, loose stools.

He had an episode of vomiting 2 days back  which is non bilious , non projectile, non foul smelling with food particles as content.

He also complained of decreased urine output from 1 day which is associated with burning micturition which is more during the start of urinary flow and relieved after urination. 

Past history:

Known case of hypertension -10 years and on regular medication ( Tab.Telmisarton - 40 mg)

Not a known case of diabetes, asthma, epilepsy, CVD, TB.

Past surgical history - underwent nephrectomy 27 years back and had cataract surgery  for right eye 3 months back. 

Personal history:

Appetite: Normal

Diet: Mixed

Sleep: adequate

Bowel : regular

Bladder: decreased urine output from 2 days with burning micturition 

Addictions: 

Occasionally consumes around 90 ml of alcohol and smokes 2 - 3 beedis per day.

Stopped smoking and drinking after nephrectomy surgery .

No drug and food allergies 

Family history:

No significant family history

GENERAL EXAMINATION:

Patient is conscious, cohorent,cooperative and well oriented to time, place and person.

Moderately built and nourished. 

Pallor- present

Icterus- absent

Clubbing-absent

Lymphadenopathy- absent

Cyanosis- absent

Pedal edema - pitting type (B/L grade 1), not relieved on rest. 

VITALS: 

B.P:110/70 mmhg

P.R:80 bpm

R.R: 14cpm

Temp:101 F

SPO2: 99%@15L O2

GRBS: 152mg/dl

SYSTEMIC EXAMINATION:

PER ABDOMEN:

Inspection - 

          Umbilicus - inverted
          All quadrants moving equally with respiration
          No scars, sinuses and engorged veins , visible pulsations. 

          Hernial orifices- free.

Palpation -  

soft, non-tender

no palpable spleen and liver

Percussion - tympanic note heard 

Auscultation- normal bowel sounds heard. 

                

CARDIOVASCULAR SYSTEM:

Inspection:

Shape of chest- elliptical 

No precordial bulge or pulsations 

JVP - not raised 

Palpation:

Apical impulse was felt at 5th intercoastal space 1 cm medial to mid clavicular line

On auscultation , S1 S2 heard  No murmurs .

RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:

 bilateral air entry present. Normal vesicular breath sounds heard.

CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes: Right.     Left. 

Biceps.      ++.          ++

Triceps.    ++.          ++

Supinator ++.         ++

Knee.         ++.         ++

Ankle        ++.         ++

PROVISIONAL DIAGNOSIS: 

AKI (secondary to urosepsis) on chronic kidney disease may be due to recurrent urinary tract infection. 

INVESTIGATIONS:

CBP:

Hb - 5.8 gm/dl

TLC -  14000 cells/ cumm

RBC - 1.8 million

PLT -  90,000 cells

CUE:

Colour- pale yellow 

Albumin- negative 

Sugars- negative 

Pus cells- plenty

Epithelial cells- 1 to 2 cells/ HPF

URINE CULTURE:

Moderate amount of pus cells seen and 

E.COLI Organism is isolated and is sensitive to all antibacterials.

RFT: 

urea - 129 mg/dl

Creatinine - 6.3 mg/dl

Electrolytes:

Na  - 137 mEq/L

K - 4.4 mEq/L

Cl - 104 mEq/L 

LFT :

 Total bilirubin- 0.63 mg/dl

 ALT - 10 IU/L

 AST - 38 IU/L

 ALP - 258 IU/L

 albumin - 2.98 gm/dl

 A/ G ratio - 1.41

ECG:

USG of abdomen:

• Raised echogenicity of right kidney
•  Normal size of kidney ( Rt. side)
•  Mild hydronephrosis
•  left kidney - not visible

Report:

TREATMENT:

1.INJ.LASIX 40 mg IV/BD 

2.INJ PIPTAZ 4.5gm IV/STAT 

3.INJ.PANTOP 40 mg IV/OD

4.INJ ZOFER 4 MG IV/SOS

5.TAB.NICARDIA- 10 mg OD

6.TAB. OROFER, OD

7.CREMAFFIN syrup 15ml PO/SOS

8.ARISTOZYME syrup 10ml , TID

9.STRICT I/O CHARTING