80 YRS OLD MALE WITH UREMIC ENCEPHALOPATHY POST RENAL AKI SECONDARY TO VESICAL CALCULUS

December 15, 2021
80 yrs old male Patient came to casualty with
 c/o burning micturition since 15 days
 fever since 5 days 
decreased urine output since 4 days, 
sob since 4 days
Hematuria + for 3 days

HOPI : Patient was apparently normal 8 years back then he had pain abdomen a/w fever and vomitings and diagnosed with ? Liver abscess and needle aspiration was done.
4 years back patient developed a blister over right ankle which ruptured and for ulcer and cellulitis debridement was done. Since 15 days patient had c/o burning micturition associated with fever, nausea, vomitings and treated accordingly. Fever since 4-5 days, intermittent,not a/w chills and rigors.no loose stools
PAST HISTORY : No HTN/DM/TB
ROUTINE HISTORY :
                        NON ALCOHOLIC/NON SMOKER
DEIT:VEGETARIAN Takes two times meal skips afternoon lunch 
Farmer by occupation
General examination :

Pt is conscious,coherent and cooperative.thin built and malnourished.
Palor+
No icterus
No clubbing
No lymphadenopathy
No edema
 
Vitals :

Temp : Afebrile
BP : 170/90 mm Hg
PR : 118 bpm
RR : 16 cpm
GRBS : 114 mg / dl
SpO2 : 98 % @2 lit O2

Systemic Examination :
CVS : S1S2 + , No murmurs
RS : BAE + , NVBS +
P/A : Soft , Nontender , BS +
CNS : HMF intact,mood disturbences

PROVISIONAL DIAGNOSIS :
URAEMIC ENCEPHALOPATHY 
POST RENAL AKI SECONDARY TO(? VESICAL CALCULUS)
? CHRONIC CYSTITIS/? PYELONEPHRITIS
PROSTATOMEGALY GRADE
INVESTIGATIONS :
Plan of treatment :
INJ.PCM 1 GM /IV/SOS
INJ.PAN 40MG/IV/SOS
INJ.ZOFER 4MG/IV/TID
IVF NS@UO+30ML/HR
TAB.NICARDIA 10 MG/PO/STAT
BP/PR/TEMP MONITORING 4TH HOURLY
TAB. NODOSIN 500MG/PO/TID
INJ.PIPTAZ 4.5GM/IV/STAT



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