57/M with pain in loin

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A 57 year old male resident of narketpally came to the OPD with chief complaints of pain in the right loin , frothy urine ,fever and decreased appetite since 10 days.


HOPI:
patient was apparently asymptomatic 10 days back then he had pain in the right loin region which is insidious in onset and gradually progressive not associated with nausea vomiting and loose stools.
H/o frothy urine fever with chills and rigor and decreased appetite since 5 days.
Altered sensorium since 4 days.
No H/o cold cough.


Past history : He is a known case of renal failure since 1 year.
NSAID abuse.
No history of allergies , asthma, epilepsy, TB, any thyroid disorders HTN DM .

Family History: Not significant

Treatment History: NSAID .

Personal history : 
 
Diet ‐ mixed.
Appetite ‐ decreased.
Sleep ‐ inadequate.Sleep is interrupted by abdominal pain.
Bowel and Bladder movements ‐ irregular.
Micturition abnormal.
Addictions: None.

General Examination: the patient is conscious, coherent, cooperative, moderately built and nourished.
Pt is Pallor
,Icterus, cyanosis, clubbing, generalised lymphadenopathy absent 
 Pedal edema is present. 


VITALS : 
Temperature ‐Afebrile.
Pulse rate ‐ 118 bpm
BP ‐ 110/80 mmHg
RR 30 cpm
SpO2 :98%
GRBS 116 gm/dl.Systemic Examination :
RS: BAE+, clear No wheeze ,dyspnoea.
CVS: S1 S2 + , NO added sounds or murmers.
P/A: soft and tender .No organomegaly.
CNS : No focal Neurolical deficit.
Provisional diagnosis:
AKI on CKD secondary to NSAID Abuse and anaemia secondary to renal failure.

Treatment:

1.FWID and salt restrictions.
2.Inj LASIX 40mg IV BD
3.INJ PANTOP 40 mg IV BD.
4.INJ TRAMADOL 1 amp in100ml NS BD.
5.inj NEOMOL 1g IV 80s
6.Tan PCM 500 mg po TID.
7.Tab NODOSIS 500 Mg po TID.
8.Tab SHEZCAL 500 mg po TID.
9.Cap BIO D3D3 po weekly once.
10. Monitor vitals 4 hourly.


Update : 
1/8/22
Central line was placed and patient was taken for dialysis in view of uremic encephalopathy

2/8/22
In view of decreased sats and no improvement in condition of patient 
Elective intubation was done 

At around 1pm afternoon 
In view of absent bp and pr  Cpr was initiated
Despite efforts patient couldn't be resuscitate and declared dead

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