40M PAIN ABDOMEN, ascites, oliguria 2 DAYS Congenital Neural tube defect Telangana PaJR 27/10/23

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. 


Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.





This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.




I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.



40 Y OLD MALE WAS BROUGHT TO CASUALITY WITH C/O PAIN ABDOMEN SINCE 2 DAYS
VOMITING SINCE 1 DAY
DECREASED URINE OUTPUT SINCE 1 DAY
NO URINE OUTPUT SINCE 8 HOURS
HOPI-
PT WAS APPARANTLY ASSYMPTOMATIC 3 DAYS BACK THEN HE DEVELOPED PAIN ABDOMEN ; DRAGGUNG TYPE OF PAIN IN EPIGASTRIUM AND UMBILICAL REGION NOT RADIATING INCREASE WITH FOOD INTAKE
DISTENTION OF ABDOMEN IS PRESENT
VOMITINGS PRESENT 1 EPISODE PER DAY
NOT BILIOUS AND NON PROJECTILE 
NOT BLOOD TINGED
DECREASED URINE OUTPUT SINCE 1 DAY
NO FACIAL PUFFINESS,FEVER,BURNING MITURITION.
NO H/o SOB, CHEST PAIN,BLURRING OF VISION,HEADACHE.

PAST H/O
HE HAD NEUROGENIC BLADDER AT AGE OF 7 YEARS
HE HAD A SWELLING ON MIDLINE LOWER LUMBAR REGION WHICH IS ABOUT 2×2 CM SINCE BIRTH 
AT THE AGE OF 7 YEARS HE GOT OPERATED ON THAT SWELLING AND SINCE THEN HE DEVELOPED NEUROGENIC BLADDER FOR WHICH HE WAS CONSERVATIVELY MANAGED WITH FEW MEDICATION 
K/C/O CKD SINCE 10 YEARS ON CONSERVATIVE MANAGEMENT AND ON FOLEYS 
K/C/O HTN SINCE 1 YEAR IT IS DIAGNOSED ON A ROUTINE EXAMINATION AS A PART OF TREATMENT TO CKD
H/O BACKPAIN SINCE 5YEARS
N/K/C/O DM; ASTHMA; CAD; THYROID ; EPILEPSY 

PERSONAL H/O
MIXED DIET
APPETITE- DECREASED SINCE 1 WEEK
BOWEL- REGULAR
BLADDER NEUROGENIC 
ADDICTIONS-
SINCE 20 YEARS OCCASIONALLY
STOPPED SINCE 4 DAYS

FAMILY H/O-
NOT SIGNIFICANT 

GENERAL PHYSICAL EXAMINATION-

PT IS CONSCIOUS COHERENT COOPERATIVE 
MODERATELY BUILT AND NOURISHED 
NO SIGNS OF PALLOR ICTERUS CYANOSIS CLUBBING GENERALISED LYMPHADENOPATHY PEDAL EDEMA
VITALS
TEMP- 99F
BP-140/90 mm of Hg
PR- 105bpm
RR-28 cpm
Spo2- 99%
Grbs-108 mg%
 
SYSTEMIC EXAMINATION 
CVS-S1; S2 HEARD, NO MURMURS 
RS- BAE+ NVBS+
ABDOMEN-
INSPECTION-
SHAPE- DISTENDED
HERNIAL ORIFICES - NORMAL
NO VISIBLE PULSATIONS, NO VISIBLE PERISTALSIS
NO SCARS; NO SINUSES, NO FISTULAS
PALPATION- ALL INSPECTORY FINDINGS ARE CONFIRMED BY PALPATION 
NO LOCAL RISE OF TEMPERATURE AND TENDERNESS 
NO PALPABLE MASS
NO ORGANOMEGALY 
PERCUSSION-
DULL NOTE ON RIGHT LUMBAR; LEFT LUMBAR; RIGHT ILIAC ; LEFT ILIAC REGIONS

ASCULTATION-
BOWEL SOUNDS HEARD

CNS-LEVEL OF CONSCIOUSNESS - CONSCIOUS 

SPEECH - NORMAL

MENINGEAL SIGNS- ABSENT

CRANIAL NERVES- NORMAL

MOTOR SYSTEM- RT LT                

           

TONE UL N N

             LL N N

SENSORY SYTEM - NORMAL

GLASGOW SCALE- EVM 15/15

POWER RT LT

UL 3/5 3/5

LL 3/5 3/5 

REFLEXES RT LT

BICEPS +3. +3

TRICEPS. +3. +3

KNEE REFLEX +3. +3

SUPINATOR +2 +2

ANKLE JERK +3 +3

PLANTAR REFLEX Flexor B/L

CEREBELLAR SIGNS- NORMAL

       



RENAL AKI ON CKD STAGE V SECONDARY TO REFLUX UROPATHY(NEUROGENIC BLADDER)
WITH LOW SAAG HIGH PROTEIN ASCITIS 

TREATMENT 

1.FLUID RESTRICTION LESS THAN 

1.5 L/DAY

2.SALT RESTRICTION LESS THAN

 2 G /DAY

3.INJ PAN 40 MG IV/OD

4.INJ ZOFER 1G IV /SOS

5.INJ LASIX 40MG IV/BD

6.INJ BUSCOPAN 1 AMP /IM/SOS

7.INJ EPO 4000 IV /SC/ ONCE WEEKLY

8.TAB.NODOSIS 500 MG PO/TID

9.TAB OROFER XT PO/OD 

10.TAB.SHELCAL - PO/OD

11.TAB ARKAMINE 0.1MG /PO/TID

12.TAB MINIPRESS XL 2.5 MG PO/OD

13 TAB SEVELEMAR 400MG /PO/BD

14.SYP POTKLOR 10ML IN GLASS OF WATER PO/TID





Ward :AMC
Unit : 4
DOA : 26/10/2023

S : 
PAIN ABDOMEN DECREASED 
FLATUS PASSED
STOOLS- NOT PASSED




O:  
Patient is conscious coherent and cooperative  
Pallor ,icterus 
clubbing, cyanosis, lymphadenopathy, oedema.- Absent

Vitals :   
Temperature -96.8F
BP- 130/80mmHg 
PR -102 bpm 
RR-20 cpm 
Grbs:137mg/dl
SPO2- 96 ON RA
I/O- 1350/650ml

CVS: S1,S2 heard , no murmurs.
RS: BAE+NVBS heard ,no added sounds.
P/A: Soft ; tenderness present in epigastric region, Bowel sounds+

CNS - 
LEVEL OF CONSCIOUSNESS - CONSCIOUS 
SPEECH - NORMAL
MENINGEAL SIGNS- ABSENT
CRANIAL NERVES- NORMAL
MOTOR SYSTEM- RT LT                
           
TONE UL N N
             LL N N
SENSORY SYTEM - NORMAL
GLASGOW SCALE- EVM 15/15
POWER RT LT
UL 3/5 3/5
LL 3/5 3/5 
REFLEXES RT LT
BICEPS +3. +3
TRICEPS. +3. +3
KNEE REFLEX +3. +3
SUPINATOR +2 +2
ANKLE JERK +3 +3
PLANTAR REFLEX Flexor B/L
CEREBELLAR SIGNS- NORMAL
       
A-RENAL AKI ON CKD STAGE V SECONDARY TO REFLUX UROPATHY(NEUROGENIC BLADDER)
WITH LOW SAAG HIGH PROTEIN ASCITIS SECONDARY TO ? PANCREATITIS? PERITONITIS (SBP) WITH ANEMIA SECONDARY TO ?CHRONIC DIASEASE
 ?BLOOD LOSS WITH UNCONTROLLED HTN

P:
1.FLUID RESTRICTION LESS THAN 
1.5 L/DAY
2.SALT RESTRICTION LESS THAN
 2 G /DAY
3.INJ PAN 40 MG IV/OD
4.INJ ZOFER 1G IV /SOS
5.INJ LASIX 40MG IV/BD
6.INJ BUSCOPAN 1 AMP /IM/SOS
7.INJ EPO 4000 IV /SC/ ONCE WEEKLY
8.TAB.NODOSIS 500 MG PO/TID
9.TAB OROFER XT PO/OD 
10.TAB.SHELCAL - PO/OD
11.TAB ARKAMINE 0.1MG /PO/TID
12.TAB MINIPRESS XL 2.5 MG PO/OD
13 TAB SEVELEMAR 400MG /PO/BD
14.SYP POTKLOR 10ML IN GLASS OF WATER PO/TID




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