A 24 yr old male came to casuality with reduced urine output.

March 13, 2022


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A 24 year old male patient, resident of Devarakonda, Cowherd by occupation came to our hospital with chief complaints of-

1. Reduced urine output with involuntary in action

2. Shortness of breath which is insidious in onset, gradually progressive

3. Pedal edema.


Date of admission :- 09/03/2022


History of present illness:-

Patient was apparently asymptomatic 10 days back and developed fever which is insidious and intermittent, and reduced urine output with involuntary in action.


History of past illness:-

Not a known case of diabetes, hypertension, tb, epilepsy

10 years ago he had same problem.


Personal history:-

Patient has normal eating habit with mixed diet.

No alchohol consumption and no smoking.


Daily routine:-

Patient used to wake up at 7.00AM , takes breakfast at 9.00AM .Then he goes to his work and takes rice in between 4.00PM-5.00PM and dinner at 8.00PM and goes to bed by 9.00PM.


Family history:-

No significant family history.


General examination:-

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

Pallor present

No icterus

No clubbing

No lymphadenopathy

Pedal edema present


Vitals:-

Temperature-99 F

Pulse rate- 88 bpm

RR-22 /min

BP-180/100 mmhg

SPO2-97% at room air

RBS-122 mg/dl

Investigations:-

CUE

Hemogram

RFT

LFT

ABG

Serum electrolytes

Serum creatinine

Blood urea

Chest X-ray

ECG

Non-contrast computerized tomography (NCCT)

X-ray right foot

X-ray left hand

Ultra sound scan of abdomen


Provisional diagnosis:-

AKI on CKD

Abscess of right dorsum of foot

Neurogenic bladder

Bladder outflow obstruction

Urinary tract tb

Severe hydronephrosis with thinned out renal parenchyma

Thickened urinary bladder wall

Peripheral lung consolidation with relative central lucency in right lung middle and lower lobe 

Peripheral consolidation in left lower lobe

Fungal infection

Covid-19 pneumonia

Septic emboli


Treatment-

Inj. Piptaz 2.25mg × IV × QID

Inj. Clindamycin 300mg × IV × TID

Inj. Pantop 40mg × IV × SOS

Inj. Lasix 40mg × IV × BD

Tab. Nodosis 500mg × PO × BD

Tab. Shelcal 500mg × PO × OD

Tab. Fluconazole 150mg × PO × BD

Cap. BIO-D3 0.25mg × PO × OD

Syp. Potchlor 10ml  × PO × TID





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