A 48 yr old male came to the opd on 25/12/22 with the chief complaints of abdominal pain since 5 days and constipation since 5days .
HOPI : patient was apparently asymptomatic 5 days back then he developed abdominal pain which was insidious in onset and gradual in progression. Pain is in the left quadrant . Pain is subsided in a day. History of constipation since 5 days because of which abdominal distension is present . Patient passed stools after giving enema and abdominal distension also decreased after giving.
Initially patient has decreased urine out put but now
Patient complaints of increase in frequency and the urgency of urine for which solifenacin is given .
5 months back patient had complaints of abdominal pain , fever and vomiting for which he went to the local hospital and symptoms decreased.
1 1/2 year back patient has chest pain for which he went to hospital and diagnosed as coronary artery disease for which stent placement is done . After this surgery patient complaints of short of breath which is of grade 2 .
Patient has underwent 2 cycles of dialysis.
No history of pedal Edema, facial puffiness .
No history of orthopnea and
No history of fever.
No history of burning micturation
Daily routine :
He wakes up at 7;00 am in the morning and takes his breakfast at 8:00am then he watches to for some time .
In the afternoon he takes lunch at 1:30pm and sleeps for about 2hr in the afternoon.
In the evening patients goes for walk about for half an hour.
He takes his dinner at 8;30pm and sleeps at 9:30pm.
Past history:
known case of diabetes since 10 yrs and hypertension since 11/2 year.
H/o coronary artery disease present .
H/o emphysematous pyelonephritis is present in July 2022.
No history of asthma , tb , epilepsy .
Drug history:
Insulin for diabetes twice daily .
Metoprolol succincte tablets for HTN daily in the morning.
Atorvastatin and clopidogrel for CAD .
Aspirin tab.
Family history: no significant family history.
Personal history:
Appetite - normal
Sleep- adequate
Bowel and bladder - regular
Addictions - chronic smoker since 20 years .(1 pack of bidis per day ) now he quit smoking since 2 years.
Drinks alcohol occasionally.
Genera Examination :
Patient is conscious,coherent,and cooperative, well oriented with time place and person.
Vitals : temp- afebrile.
RR- 18/min
BP- 150/70mmhg
PR-90bpm
Pallor is present
No icterus , clubbing , cyanosis , lymphadenopathy, pedal edema.
Systemic examination:
CVS : s1 and s2 are heard . No murmurs.
Abdomen : abdomen is soft and non tender .
No organomegaly , no scars and no hernial
Orifices.
CNS : no focal neurological deficits.
RS : normal vesicular breath sounds are heard .
Provisional diagnosis : AKI ? With history of emphysematous pyelonephritis .
Dialysis report:
On 26/12/22
On 28/12/22
INVESTIGATIONS :
On 25/12/22
On 26/12/22
On 27/12/22
On 30/12/22
On 31/12/22
On 3/1/23
TREATMENT:
Fluid and salt restriction.
Hemodialysis done on 26/12/22 and 28/12/22
INJ Amikacin 250g iv od .
INJ Lasix 20mg iv BD
Tab nodosis 500mg BD
Tab Nicardia 20mg p/0 BD
Tab solifenacin .
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