64 YEAR MALE WITH DECREASED URINE OUTPUT AND SHORTNESS OF BREATH
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5 jan 2022
A 64 year old male patient presented to the OPD with chief complaints of decreased urine output since 9days and shortness of breath grade II-III since 4days And pedal edema since 7days.
HISTORY OF PRESENT ILLNESS
✓64 year old male patient resident of gollaguda,unemployed. He was apparently asymptomatic 4 years back then he had an injury to chest which led to left rib fractures(5,6,7) at mid clavicular line and punctured the lung which led to hemoptysis for a month and settled down and incidentally diagnosed with hypertension was kept on T.ATEN AM 50mg and T.Amlong 5mg,after an year he had an injury to abdomen and incidentally diagnosed with type 2 diabetes was kept on T.Metformin 500mg.13days ago he had an injury to right foot with a sharp object(stone) gradually bleb was formed over dorsum of foot which ruptured spontaneously and developed an ulcer.
✓Decreased urine output since 9days
Sob grade II-III with orthopnea and pnd since 7days
*B/l Pedal edema since 13days, insidious in onset gradually progressive to knee aggravated on walking and relieved on taking rest and medication.
*Facial puffiness since 7days
*Low grade fever since 13days,low grade,on and off,subsides on medication and not associated with chills and rigor.
*Blood in urine after foley's catheterisation days ago i/v/o low urine output
*One session of dialysis done 5days ago in a local hospital in nalgonda and 2 sessions in our hospital 2days ago i/v/o low urineoutput and raised creatinine levels.
*he has itchy skin lesions over abdomen since 6days and over both axillary area since 1day.
PAST HISTORY:
No similar complaints in the past
MEDICAL HISTORY:
known case of diabetes since 3yrs on Tab.Metformin, hypertension since 4yrson Tab.ATEN,
Not a k/c/o tuberculosis, epilepsy, asthma.
FAMILY HISTORY:
No relevant family history
PERSONAL HISTORY:
-Mixed diet
-appetite normal
-Adequate sleep
-Regular bowel movements
-micturition: Pt HAS DECREASED URINE OUTPUT.
Alcoholic since 30yrs
Last binge 15 days back.
Smoker since 30yrs.
GENERAL PHYSICAL EXAMINATION:
PALLOR - absent
Icterus - Absent
Cyanosis - Absent
Clubbing - Absent
Lymphadenopathy - Absent
Pedal oedema - PRESENT ( PITTING TYPE)
Vitals:
Temperature- afebrile
Pulse rate- 68 beats per minute
Respiratory rate- 22 breaths per minute
B.P- 120/60 mm hg
SpO2- 99% at room air
SYSTEMIC EXAMINATION
Cardiovascular system- s1 and S2 are heard no murmurs are heard
Respiratory system:
Dyspnoea- present
Breath sounds- decreased breath sounds in right
Vesicular breath sounds are normal
Rt side Fine Crepts present
BAE- positive
Central nervous system- Patient was conscious coherent and cooperative.
Speech was normal.
No slurred speech
No meningeal irritation signs
-No abnormality detected.
GAIT - Normal
Clinical images:
