61 year male with pain in left loin, decreased urine output,fever and constipation
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A 61 year old male resident of agaram came to the OPD with chief complaints of pain in the left loin , decreased urine output,fever and constipation since 10 days.
HOPI:
patient was apparently asymptomatic 10 days back then he had one episode of vomiting followed by fever associated with chills and rigors.Then he had pain in the left loin which is associated with decreased urine output.Then he also developed constipation with diffuse pain in the abdomen.The pain in the left loin region is sudden in onset and fluctuating type.The pain aggregates on lying on the bed and decreases on sitting position.
Past history : He is a known case of diabetes and hypertension.
No history of allergies , asthma, epilepsy, TB, any thyroid disorders .
Family History: Not significant
Treatment History: He is on the treatment of HTN since 1 year and on DM since 3 years.
Personal history :
Diet ‐ vegetarian.
Appetite ‐ normal
Sleep ‐ inadequate.Sleep is interrupted by abdominal pain.
Bowel and Bladder movements ‐ iregular and and on alternate days.
Addictions: He had the history of smoking and consuming alcohol 3 years back .
General Examination: the patient is conscious, coherent, cooperative, moderately built and nourished.
No Pallor,Icterus, cyanosis, clubbing, generalised lymphadenopathy,
Bilateral Pedal edema is present.
VITALS :
Temperature ‐ 99.8F
Pulse rate ‐ 86 bpm
BP ‐ 130/80 mmHg
RR 22cpm
SpO2 :98%
RS: BAE+, clear No wheeze ,dyspnoea.
CVS: S1 S2 + , NO added sounds or murmers.
P/A: soft and tender .No organomegaly.
CNS : No focal Neurolical deficit.
Investigations:
Provisional diagnosis
Acute kidney injury associated with fever and secondary to UTI.
Treatment:
1.Inj LASIX 40 mg IV/ STAY
2.Inj NEOMOL 1g IV/STAY
3.Inj SODIUM BOCARB 50 mEq IV/ STAY
4.Inj NTG 4 ml NS.
27/08/22
Diagnosis: Acute kidney injury associated with fever secondary to UTI.
One episode of dialysis done in the morning and one fever spike since admission.
O/E
Pt. Is conscious coherent and copertative
PR 97 BPM
RR 26 cpm
TEMP 99.3F
BP 110/70mmHg
GRBS 146 mg/dl.
RS :BAE + ,clear
CVS: S1,S2 Heard , no added sounds
CNS :NO abnormalities
P/A Soft and tender.
Plan of treatment
1.INJ LASIX 40 mg IV/BD if SBP >110 mmHg.
2.Inj MAGNEX FORT15 mg IV /BD.
3.Inj NEOMOL 1g Iv if temp >101.3F
4.Tan NODOSIS 500mg Po/BD
5.Tab SHELCAL 500mg Po/OD
6.Tab DOLO 650 mg PO/TID.
7.Inj PAN 40 mg IV /OD.
8.Syr CREMAFIN 65 mlPO/HS.
9.GRBS 6th hourly.
28/08/22
Diagnosis: Acute kidney injury associated with fever secondary to UTI.
Acute pulmonary edema
Emphysematous pyelonephritis L>R.
O/E
Pt. Is conscious coherent and copertative
PR 82 BPM
RR 22 cpm
TEMP 99.3F
BP 90/60mmHg
GRBS 164 mg/dl.
RS :BAE + ,clear
CVS: S1,S2 Heard , no added sounds
CNS :NO abnormalities
P/A Soft and tender.
Plan of treatment
1.INJ MEROPENEM 500mg IV/BD
2..INJ LASIX 40 mg IV/BD if SBP >110 mmHg.
3.Inj MAGNEX FORT1.5 mg IV /BD.
4.Inj NEOMOL 1g Iv if temp >101.3F
5.Tan NODOSIS 500mg Po/BD
6.Tab SHELCAL 500mg Po/OD
7.Tab DOLO 650 mg PO/TID.
8.Inj PAN 40 mg IV /OD.
9.Syr CREMAFIN 65 mlPO/HS.
10.GRBS 6th hourly.
29/08/22
Diagnosis: Post Renal Acute kidney injury associated with Emphysematous Pyelonephritis L>R.
HTN/DM.
Acute pulmonary edema [Resolved].
C/o pain on left side of lumbar region.
O/E
Pt. Is conscious coherent and copertative
PR 122 BPM
RR 30 cpm
TEMP 101 F
BP 130/70mmHg.
SpO2. 97%
RS :BAE + ,clear
CVS: S1,S2 Heard , no added sounds
CNS :NO abnormalities
P/A Soft and mild tender in left hypochondrial region.
Plan of treatment
1.IVF NS @100 ml/hr.
2..INJ LASIX 40 mg IV/BD if SBP >110 mmHg.
3.Inj MEROPENEM 500mg IU/BD.
4.Inj NEOMOL 1g Iv if temp >101.3F
5..Tan NODOSIS 500mg Po/BD
6.Tab SHELCAL 500mg Po/OD
7.Tab DOLO 650 mg PO/TID.
8.Inj PAN 40 mg IV /OD.
9.INJ TRAMADOL 1AMP IN 100 ml NSIV/TID.
10.GRBS 6th hourly.
11.syp CREMAFINplus 10ml po/HS.
12.GRBS 6th hourly.
30/08/22
Diagnosis: Post Renal Acute kidney injury associated with Urosepsis.
Emphysematous pyelonephritis
HTN/DM.
Acute pulmonary edema.(L>R).
One fever spike yesterday 101 F
O/E
Pt. Is conscious coherent and copertative
PR 122 BPM
RR 30 cpm
TEMP 99.3F
BP 120/60mmHg.
SpO2. 97%
RS :BAE + ,clear
CVS: S1,S2 Heard , no added sounds
CNS :NO abnormalities
P/A Soft and mild tender in left hypochondrial region.
Plan of treatment
1.IVF NS @100 ml/hr.
2..INJ LASIX 40 mg IV/BD if SBP >110 mmHg.
3.Inj MEROPENEM 500mg IU/BD.
4.Inj NEOMOL 1g Iv if temp >101.3F
5..Tan NODOSIS 500mg Po/BD
6.Tab SHELCAL 500mg Po/OD
7.Tab DOLO 650 mg PO/TID.
8.Inj PAN 40 mg IV /OD.
9.INJ TRAMADOL 1AMP IN 100 ml NSIV/TID.
10.GRBS 6th hourly.
11.syp CREMAFINplus 10ml po/HS.
12.GRBS 6th hourly.
13.Monitor vitals 4 hourly.
31/08/22.
Diagnosis: Post Renal Acute kidney injury associated with Urosepsis.
Emphysematous pyelonephritis
HTN/DM.
Acute pulmonary edema Resolved.
O/E
Pt. Is conscious coherent and copertative
PR 84 BPM
RR 22 cpm
TEMP 99.3F
BP 120/70mmHg.
SpO2. 97%
GRBS 154 mg/dl.
RS :BAE + ,clear
CVS: S1,S2 Heard , no added sounds
CNS :NO abnormalities
P/A Soft and mild tender in left hypochondrial region.
Plan of treatment
1.IVF NS @100 ml/hr.
2..INJ LASIX 40 mg IV/BD if SBP >110 mmHg.
3.Inj MEROPENEM 500mg IU/BD.
4.Inj NEOMOL 1g Iv if temp >101.3F
5..Tan NODOSIS 500mg Po/BD
6.Tab SHELCAL 500mg Po/OD
7.Tab DOLO 650 mg PO/TID.
8.Inj PAN 40 mg IV /OD.
9.INJ TRAMADOL 1AMP IN 100 ml NSIV/TID.
10.Syp CREMAFFIN Plus 100mlPO/HS.
11.GRBS 6th hourly.
12.Monitor vitals 4 hourly.
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