65 yr old with acute on chronic kidney disease

Roll no 04 
Hi, i am lasya, 8th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent. This also reflects patients centered care and online learning portfolio. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. Hope this will be informative!


A 65 yr old male came to OPD with chief complaints of decreased urine output since 6 days , burning micturition since 6 days , pain abdomen since 5 days . 
 
History of presenting illness : 
Patient was apparently asymptomatic 6 months back when he had constipation. 




Then , 17 days back he developed fever which was sudden in onset , intermittent , high grade which was associated with chills and rigors , and got relieved by taking medication. 

He then had burning micturition and decreased urine output after 2 days of fever which was insidious in onset and gradually progressive .
He presented with pain abdomen which is of squeezing type and is present in all quadrants  and distension of abdomen and limbs ( decreased ) 

H/o shortness of breath grade 2 
No h/o haematuria 
No h/o vomitings

Past history: 
Not a k/c/o 
DM
HTN
TB
Epilepsy
Thyroid disorders 
Asthma 

Treatment history: not significant

Personal history:

Diet : mixed
Appetite: decreased 
Bowel and bladder movements : constipation , decreased urine output  and Burning
                                                           Micturition

                                                  
Addictions : occassionally drinks since 30 yrs , 
Smoking since 30 yrs .
Sleep : adequate
No known allergies 

FAMILY HISTORY:
Not significant

PHYSICAL EXAMINATION: 
GENERAL : 
Patient is conscious, coherent, cooperative
No pallor 
No cyanosis
No icterus
No lymphadenopathy 
No clubbing
Oedema present .
Vitals : 
Temperature: 98.7°c 
Pulse rate : 86/min
Respiration rate : 26/min
BP : 100/60
Spo2: 90
GRBS : 136 mg/dl

SYSTEMIC EXAMINATION: 

CVS : s1 s2 heard , no murmurs , no thrills
RS : position of trachea: central 
        Breath sounds : vesicular 
        Wheeze : absent 
        Dyspnea : present 
PA : 
Shape of abdomen : scaphoid 
Tenderness : present in all quadrants
No palpable mass
Hernial orifices : normal
No free fluid
No bruits 
Liver and spleen : not palpable 
Bowel sounds : heard

CNS :
Conscious 
Speech : normal
Signs of meningeal irritation : 
Neck stiffness : absent 
Kernigs sign : absent 
Cranial nerves : intact 
Motor system : normal 
Sensory system: normal
Glassgow coma scale : 15/15

Reflexes : 




PROVISIONAL DIAGNOSIS : 
Acute on chronic kidney disease 

Investigations : 


2D ECHO










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