57 yr male with decreased Urine output

 This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed 


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


Chief complaints:

Pedal edema since 7 days

Decreased Urine output 2 days

Sob grade 2 since 1 day

Excess sweating since 4hrs

HOPI:

pt was apparently asymptomatic 15 years back then he developed polyuria,polyphagia and diagnosed with DM,  then started on OHA. 5 yrs back pt developed weakness of rt upper and lower limb and diagnosed with hypertension and started on MET-XL 25mg.

Now since 7 days patient developed b/l pedal edema , pitting type upto knee . Decreased Urine output since 2 days associated with burning micturation associated with urgency, hesitancy, and not associated with fever. 

Sob grade 2 gradual in onset since 1 days not associated with cough and chest pain .

K/c/o DM SINCE 15YRS  on GLUCONORM

K/C/O HTN SINCE 5YRSBON MET-XL 25mg

Personal history:

Diet- mixed

Appetite normal

Sleep adequate

BLADDER - decreased Urine output

Bowel movements normal

He is occasional alcoholic since 35 yrs and 360ml/day for 30 yrs and decreased to 180 ml/day since 5 years.

General examination:

















No pallor ,icterus ,cyanosis, clubbing, lymphadenopathy  .

b/l pedal edema .

TEMP- Afebrile

PR - 102 bpm

RR - 16 cpm

BP - 190/120 mmHg 

GRBS - 55.

Diagnosis: 

AKI SECONDARY TO DIABETIC NEPHROPATHY, WITH RECURRENT HYPOGLYCEMIA SECONDARY TO OHA INDUCED.

TREATMENT:

1.INJ. 25%DEXTROSE INFUSION @50ml/hr

2. IVF 1 UNITB@ URINE OUTPUT+ 30ml/hr

3. TAB. LASIX 40mg IV/BD

4. TAB. NICARDIA 20mg PO/BD

5. TAB ARKAMIN 0.1 mg PO/TID

6. TAB. NODOSIS 500mg PO/BD

7. TAB. SHELCAL 500 mg PO/BD

8. TAB BIOD3 WEEKLY ONCE.

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