A 75 year old male with CKD
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Date of admission: 10/01/23
Chief complaints: A 75 year old male was brought to the casualty with chief complaints of decreased urine output since 1 week and shortness of breath since 1 week
History of present illness: Patient was apparently asymptomatic 3 months back and then he developed lower limb cellulitis of left leg and debridement was done with dressings.
Patient had uncontrolled sugars with 500mg/dL blood sugar level, and was diagnosed with UTI
Patient developed fever with chills and loose stools.
Burning sensation of right lower limb
Burning micturition and was treated with antibiotics.
Patient developed decreased urine output and shortness of breath and 4 sessions of hemodialysis was done
PRBC transfusion was done.
History of past illness: patient is a k/c/o DM since 12 years and is on medication
k/c/o of HTN
Known case of Chronic kidney disease since 5 years
Clinical examination:
GENERAL EXAMINATION
• Pallor - absent
• Icterus - Absent
• Clubbing - Absent
• Koilonychia - Absent
• Lymphedenopathy - Absent
• Pedal oedema - absent
• JVP - Normal
VITALS
• Temperature - 99°F
• Pulse rate - 98bpm
• Respiratory rate - 20 cpm
• BP - 160/80 mmHg
• SPO2 - 97% on room air
Systemic Examination:
CARDIOVASCULAR SYSTEM:
No Thrills,
S1,S2 sounds hears,
No murmurs.
RESPIRATORY SYSTEM:
INSPECTION:
Chest is symmetrical
Trachea:central
PALPATION:
Trachea:central
AUSCULTATION:
Vesicular breath sounds
No wheeze
ABDOMEN:
INSPECTION:
shape-scaphoid
Flanks-full
Umbilicus-everted and central position
Hernial orifices-nornal
No dilated veins
No scars and sinuses
PALPATION:
Non tender
No Local rise of temperature
No palpable Mass
Spleen and liver not palpable
AUSCULTATION:
Bowel sounds-present
CNS:
Patient is drowsy
Speech is incoherent
No signs of meningeal irritation
Cranial nerves are intact
Glass gow coma scale: E-4, V-2, M-6
Investigation
Diagnosis: Acute kidney injury on Chronic kidney Disease with cellulitis of left lower limb
Treatment:
Inj lasix 100mg iv stat
Tab nicardia 20mg
Tab nodosis 500mg
Rules tube feeding every 4th hour
