A 63 yr old male with urinary retention
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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.
CHIEF COMPLAINTS:
• Pt c/o no urine output since 2 days
• B/L pedal edema since 2 days.
•. Shortness of breath
HOPI : Patient was apparantly assymptomatic 10 days back,later which he didn’t pass urine for 2 days for which he was taken to hospital,and at that time his Systolic blood pressure was 80. So started noradrenaline drip ( according to reports)and lasix followed by which patient was shifted here.At admission he came with complaints of bilateral mild pedal edema pitting type and present till knees since two days which were gradual in onset and anuria since two days and shortness of breath since two days,for which fluids were given and no improvement in urine output was seen and so patient underwent dialysis..
PAST H/O :
K/C/O Diabetes mellitus since 4 years.
No H/O HTN,Asthma,CAD,TB
FAMILY H/O :
No significant family history.
GENERAL EXAMINATION:
P/A : Soft ,nontender.
PROVISIONAL DIAGNOSIS :
Renal AKI
INVESTIGATIONS :
TREATMENT GIVEN:
1. INJ. LASIX 40 mg IV/OD
2. INJ.MONOCEF 1gm IV/BD
3. TAB. NODOSIS 500mg PO/BD
4. TAB. PAN 40 mg PO/OD
5. TAB. SHELCAL PO/OD
6. TAB. BIO D3 PO/OD
7. TAB. NAPROXEN 200mg PO/OD
