A 67Yr Old male with burning micturition and decreased urine output.
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A 67 year old male, weaver by occupation came to causality with
#CHEIF COMPLAINTS:-
(1)Decreased urine output,
(2) Burning micturition and
(3) Lethargy since 15 days.
#HOPI:
*Patient was apparently asymptonatic one year back ,then he started experiencing altered sleep cycle.
*He was also experiencing episodes of Nocturia in this one year.
*Patient had c/o urinary Incontinence since 1 year.
*Patient had recurrent episodes of UTI (in the past 1 year). Because of his urinary incontinence, patient totally avoided social gatherings in the past 1 year.
*15 days back he had 2 episodes of vomitings, 4-5 episodes of loose stools.
*He had two episode of vomiting non-bilious, non-projectile, containing food particles. He had 4-5 episodes of loose stools per day.
*He had burning sensation in the tongue and throat since 15 days,so that he was taking only minimal water and milk.
*Patient had decreased urine output and whenever he tried to micturate associated with burning sensation in the penis, which lasted for 20mins. Because of this symptom (dysuria) he totally decreased intake of fluids so that he won't get painful urination.
*Whenever he passes urine, it totally amounts to 10ml.
*10 days back he experienced dysphagia for which he was hospitalised and was Managed for the same.
•History of fever on and off
•No history of dyspnoea, SOB palpitations ,chest pain& PND.
•No history of abdominal pain, distension.
•History of burning micturition present, •H/O pyuria present.
#Past history:
•N/A/K/O HTN, DM, HYPOTHYROIDISM, CVA, EPILEPSY
•H/O cataract surgery 2 months back.
#Personal History:-
•Diet - mixed
•Apeptite-decreased
•Bowel and bladder - regular
•Sleep - inadequate
•Addictions:-Alcoholic since 20 yrs,takes quarter daily.stopped 10 days back.
#FAMILY HISTORY:
No significant family history.
#GENERAL EXAMINATION:
O/E : Patient is C/C/C
Clubbing - Absent
Pallor - present
Icterus absent
Cyanosis - absent
Edema of feet - absent
Lymphadenopathy - absent
VITALS:-
BP: 100/70mmhg
PR: 96 bpm
RR: 20cpm
Spo2: 97%
GRBS: 79 mg/do
#SYSTEMIC EXAMINATION :
CARDIOVASCULAR SYSTEM : S1 and S2 heard, no murmurs heard
RESPIRATORY SYSTEM : BAE present, NVBS heard, position of trachea - central
PER ABDOMEN : soft, non tender.
No organomegaly.
CNS: Higher mental function intact,NAD.
#Previous reports:
12/12/2020
Hb- 13.6gm/dl
Total counts- 5,700 cells /cumm
Platelets- 3.5 lakhs
Rbs-114
13/12/2020
S. Creat-3.6mg/dl
CUE:
Pus cells- plenty
RBC- nil
EC- 2-3
22/3/22
Blood urea- 203 mg/dl
S.creat-8.4mg/dl
Abg:
PH- 7.13
PCO2- 5.6mmHg
PO2- 135mmHg
HCO3- 1.8mmol/L
23/3/22
Blood urea-190mg/dl
S.creat-8.3mg/dl
Abg:
PH- 7.17
PCO2- 8.6mmHg
PO2- 138mmHg
HCO3- 3.1mmol/L
24/3/22
Blood urea- 136 mg /dl
S.creat- 6.2mg / dl
Abg:
PH- 7.2
PCO2- 8.8mmHg
SpO2- 96.1%
HCO3- 3.5mmol/L
23/3/2022
#HEMOGRAM:-
HB :- 6.9gm/dl
Wbc:- 6,800 cells/cumm
Neutrophills :- 60%
Lymphocytes :-30%
Eosinophills:- 6%
Monocytes:-4%
Basophills:-0%
PCV :- 21.2 VOL %
MCV :- 105.5 fl
MCH:- 34.3 pg
MCHC :- 32.5%
RDW -SD :- 59.7fl
RDW -CV :- 15.3%
RBC :- 2.01 Millions/cumm
PLATELETS :- 2.32 Lakhs/cumm
ON-22/3/2022
LIVER FUNCTION TEST (LFT) :-
Total bilirubin :- 0.97mg/dl
Direct bilirubin :- 0.26mg/dl//
SGOT(AST) :- 15 IU/L
SGPT(ALT) :- 10 IU/L
Alkaline phosphatase :- 212 IU/L
Total proteins :- 7.3gm /dl
ALBUMIN :- 2.67 gm/dl
A/G Ratio :- 0.58
ON-23/3/2022
SERUM ELECTROLYTES:-
Sodium :- 142 meq/l
Potassium :- 4.4 meq/l
Chloride :- 104 meq/l
INVESTIGATION:-
USG:-
On 20-12-2019
#Diagnosis:
*Recurrent UTI secondary to ?Renal calculi
•AKI ON CKD
•metabolic acidosis
•Normochromic Normocytic anemia(2o to CKD)
#TREATMENT:
1. IVF NS & RL @100ml/hr
2. Inj. Monocef 1gm/po/nd
3. Inj. Pan 40 mg/iv/of
4. Mucopain gel oinent for L/A
5. GRBS 6th hourly
6. Vitals monitoring 4th hourly
