case 1


A 65yr old male patient masion by occupation resident of nalgonda came to old with 
Chief complaints of
-fever-4 days 
-pain abdomen -4 days 
-decreased urine output -6 days
-burning micturition-6 days 
History of present illness :
Patient was apparently asymptomatic 1 week ago then he developed decreased urine output since 6 days which is insidious in onset and gradually progressive,he also developed abdominal pain in right side of the abdomen since 4 days which is insidious in onset gradually progressive, episodic and sharp type radiating from right upper quadrant to epigastric region which is associated with back pain ,no aggravating factora but relieved on medication.
History of fever since 4 days which is low grade and intermittent.
H/o burning micturition present
Constipation since 6 months 
History of past illness: 
N/k/c/o diabetes, hypertension,asthma,tuberculosis ,epilepsy
No past medical history
Personal history:
Diet : mixed
Appetite:normal
Sleep : adequate
Bowel and bladder movements : irregular with constipation and burning micturition.
Addictions : alcoholic since 30 yrs (occasionally)
                Smoker (bd) since 30 yrs initially 1 pack /day then gradually decreased to 2 bd / day 
Family history:not significant
General examination: 
Pallor : present
No icterus, clubbing ,cyanosis,
Pedal edema present 
No lymphadenopathy 
Vitals :
Temperature: 98.7F
Pulse rate : 86/min
Respiratory rate: 26/min
BP:100/60
Spo2 :90%
Grbs: 136mg%
Systemic examination
Abdomen:
Inspection
Shape of abdomen scaphoid
No visible scars
No distension
Catheter is present in right thigh
Palpation
On  palpation tenderness  is seen in all quadrants 
No palpable masses
No hepatosplenomegaly
Auscultation
Bowel sounds are heard and normal
Cvs 
S1 and s2 are heard
No murmurs and thrills 
Respiratory system
Dyspnea is present
No wheezing
Position of trachea is central
Breath sounds vesicular
CNS
Patient is conscious
Speech normal
No signs of meningitis
Cranial nerves intact
Sensory and motor system normal
Glasgow sacle 15/15
Provisional diagnosis
Acute on CKD with multiorgan dysfunction with subacute intestinal obstruction with sepsis
Investigations
 

Treatment
INJ MEROPENAM 500mg iv/bd
INJ METROGYL 500MG IV /TID
IV FLUIDS iv/tid
INJ NEOMAL 
INJ LASIX 40MG iv /bd
TAB DOLO 650MG po/bd
SYP CREMAFIN
INJ ERYTHROPOIETIN 4000iu s/c once weekly

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