General medicine case-1

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A 55 years male patient from kondapakagudem ,presented to OPD on 04.08.2021 with a complaint of decreased urine output since 3 days.

History of present illness:-

-Patient was apparently asymtomatic till 1997 when he had fallen from the current pole after which he had injury to the left upperlimb,lowerlimb and lower back for which he had started using painkillers since many years ,till 1 month back.

-6 years back he started developing pedal edema in both limbs which is pitting type extending upto both the knees.

-6 years back he also developed knee joint pains and swelling.

-Patient had a trauma 1month back at right lower limb at the ankle due to bike accident,which got infected and medicated with some antibiotics. The wound didnot subside even after taking antibiotics.

-15 days ago he developed shortness of breathing for which he was taken to the hospital and there he was supplied with oxygen for his shortness of breathing.              There the doctors told him that his serum creatinine levels are elevated and advised him dialysis.

-While the patient is being prepared for cvp line he suffered from cardiac arrest and was resescitated.

-On first day of dialysis doctors collected fluid from his both knees.

-From then he undergone dialysis for 6 times after his 6th dialysis patient was taken home.

-After going home patient developed decreased urine output and for this reason he brought to our casuality.

Past history:-

No h/o of hypertension, diabetes mellitus,asthama,epilepsy,coronary artery disease .

Personel history:-

Diet is mixed 

Appetite is normal

Sleep is adequate

Bladder movements-decreased urine output

Bowel movements are regular

Addiction:-History of alcohol intake since past 25years.

Family history:-

No history of similar complaints in family

General Examination:-

Patient is conscious,coherent and cooperative.

No signs of pallor ,icterus,synosis and lymphadenopathy.

Clubbing is present

Edema is present in both the lower limbs which is pitting type extending upto both the knees.

Vitals:-

PR-89bpm

Bp-120/80

RR-24cpm

GRBS-136mg/dl

Temparature-98.6F

SPO2-99%  on 4L of O2

Systemic Examination:-

Cardiovascular system:-

S1,S2+.   No mururs 

 

Respiratory system:-

Bronchial artery embolisation is positive

Palpation /Auscultation:-soft,non tender,bowel sounds are heard

Central nervous system:-

No abnormality detected

Investigations:-

Chest X ray 

ECG

X ray of limbs

USG  test:- Of bilateral knee joint

-Diffuse synovial thickening with minimal joint effusion noted in right knee joint.

-Loculated collections of 2.8×3.6cm noted along the medial aspect of the left knee .

-F/S/O infective synovitis

-Rest of the visualised muscles and tendons appear normal.

Bacterial culture and sensitivity report:-

1)Nature of specimen -urine

Direct smear and wet mount:-Few pus cells,budding yeast cells seen

Culture report :- skin commensals grown.

2)Nature  of specimen:-blood

Culture report:-No growth after 1week of incubation .

Diagnosis:-

Renal Acute kidney injury (Acute tubular necrosis)on chronic kidney disease analgesics

Nephropathy with Urinary tract infection(fungal etiology)

Right lower limb cellulitis

Heart failure with preserved ejection fracture

Cholelithiasis

Rheumatoid arthritis

3SESSIONS Of HEMODIALYSIS DONE BEFORE 10.08.2021

Treatment:-

1.Fluid restriction<2L/day

2.Salt restriction<2g/day

3.Inj.Piptaz 2.25g IV /TID

4.Inj.Pan 40mg IV /OD

5.Inj .Lasix 40mg IV/BD

6.Tablet Fluconazole 100mg PO/OD

7.Protein powder 2tbsp in 100ml milk BD