70 Y/M with pain abdomen 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'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.    

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan 

8-March-2022

CHIEF COMPLAINTS

Pain abdomen since 2 days

Reduced urine output since 1 day

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 2 days ago then developed pain in right HYPOCHONDRIUM, insidious onset, gradually progressive not associated with vomitings and not relieved by bending forward position

No history of fever, loose stools, chest pain, palpitations

From 1 day patient is having decreased urine output not associated with burning micturition

PAST HISTORY

PTCA 10 yrs back 

Left-sided hearing loss in 6 years and patient is using hearing aid

Not a known case of diabetes, hypertension, asthma, tuberculosis, epilepsy

TREATMENT HISTORY

Patient is on 

1. T. Torsemide 10 mg PO OD

2. T. Isosorbide dinitrite + hydralazine 20/37.5mg PO BD

3. T. Atorvas/clopidogrel 75mg PO HS

VITALS - 

TEMPERATURE - 99.1

PULSE RATE - 87 BPM

BLOOD PRESSURE - 130/80 MM OF HG 

RESPIRATORY RATE - 30

SPO2 - 97 % AT ROOM AIR

GENERAL EXAMINATION

Patient is conscious coherent cooperative well oriented to time place and person

Pallor present

No Icterus, cyanosis, clubbing, lymphoadenopathy 

SYSTEMIC EXAMINATION - 

PER ABDOMEN : DISTENDED, umbilicus inverted SOFT, TENDER in Rt iliac fossa, Rt lumbar, rt HYPOCHONDRIUM

CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT, decreased breath sounds - Rt ISA, IAA, IMA, Fine crepitations Lt ISA, MSA

CENTRAL NERVOUS SYSTEM : NAD. 

 

HEMOGRAM

HB 11.9

TC 17,100

PLT 1.88

MCV 86.8

PCV 35.5

MCH 29.5

MCHC 34

SMEAR - NORMOCYTIC NORMOCHROMIC

BGT

A POSITIVE

RFT

Urea 47

Creatinine 2.2

S. Sodium 139

S. Potassium 3.8

S. Chloride 97

Urine chloride 142

Urine sodium 185

Urine potassium 23

Urine protein/creatinine ratio 0.11

S. Amylase 41

S. Lipase 28

CUE 

Albumin: trace

Sugar: nil

Pus cells: 2-3

Epithelial cells: 2-3

LFT

TB 1.86

DB 0.94

AST 32

ALT 20

ALP 115

TP 5.7

ALB 3.6

Ultrasound abdomen

Echo of multiple anechoic cyst is noted in both kidneys largest 5.2 X 2.4 cm and the right kidney and 5 X 4.8 CM in the left kidney

Impression:-

Bilateral grade 1 rpd with simple renal cortical cyst

Grade 1 fatty liver

Chest X ray

X Ray (erect abdomen)

ECG

ABG

PROVISIONAL DIAGNOSIS

Acute pancreatitis 

with AKI ON CKD 

WITH post PTCA (10 yr back)

With Left side hearing loss

TREATMENT

IVF NS/RL at 50 ml/hr

Inj. Tramadol 1 AMP in 100ml NS IV BD

Inj. Ceftriaxone 1g IV BD

  

SOAP NOTES 

https://sravanivv180.blogspot.com/2022/03/78-year-old-male-with-abdominal-pain.html?m=1

Current status

(14-March-2022)

Peripheral vascular disease with cor pulmonale with k/c/o CAD s/p PTCA(10years back) with CKD on conservative management with left sided hearing loss (on hearing aid since 6 years) with acute acalculus cholecystitis.

P:- 

Propped up position

Fluid and salt restriction

Inj. Lasix 40mg IV TID 8am--2pm--8pm

T. Ecosprin AV 75/10 mg PO HS

T. Met-XL 25 MG PO BD

T. Nodosis 500 mg PO SOS

T. Livogen 1 tab PO OD

T. Shelcal 500 mg PO BD

Inj. Tramadol 1 amp in 100 ml NS IV TID

Intermittent CPAP

Inj. Ceftriaxone 1g IV BD(Day 5)

Inj. Thiamine 1amp in 50 ml NS IV OD