50Y/F with complaint of decreased urine output

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's 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 inputs on the comment

April 09, 2022
50 YEAR OLD FEMALE WITH DECREASED URINE OUTPUT



Patient came to casualty with 

C/O DECREASED URINE OUTPUT SINCE 1 month. 

C/O FACIAL PUFFINESS SINCE 1 MONTH 

C/O MILD SOB SINCE - 1 MONTH 

C/O DECREASED APPETITE SINCE 1 MONTH 

HOPI :

PATIENT WAS APPARENTLY ASYMPTOMATIC THEN SHE DEVELOPED GIDDINESS AND VOMITINGS (2-3episodes )WENT TO A LOCAL HOSPITAL IN GURUJALA AND THERE SHE WAS DIAGNOSED WITH HYPERTENSION GRADE 3 (180/100 MM HG ) AND THEN SHE WAS TREATED WITH telma 40mg , amlodepine 5mg , metoprolol 50 mg .

And then after using medications her bp was uncontrolled then they went to miryalguda for uncontrolled hypertension and decreased appetite (1 idly at 8am ,50 grms of rice at 11 am , 50ml Ragi malt at 3 pm, 50ml of milk at 7pm)and decreased urine output . 

H/O shortness of breath since 1 month and present only on walking for 15 mins and relieved on sitting .

History of past illness : 

Not a k/c/o DM,TB, BA, Epilepsy 

And Thyroid disorders. 

Personal history:

Diet - mixed 

Appetite - decreased since one month 

Bowel movements: regular 

 Bladder movements : decreased 

Sleep : adequate

No addictions and allergies 

 Family history : insignificant 

NSAID ABUSE since 1yr (post covid).

General examination:

Pt is Conscious coherent and cooperative

Well oriented 

Pallor present


No signs of icterus, clubbing, koilonychia, lymphadenopathy and clubbing. 

Vitals:

Temp: afebrile 

Pulse rate :88bpm

Resp rate : 16cpm 

Blood pressure: 130/90 mm hg 



Systemic examination:

CVS - S1, S2 heard

Respiratory system - NVBS, BAE

Per abdomen -soft and non tender

CNS - NFND

INVESTIGATIONS:

Usg abd and pelvis :
Ecg :
Hemogram:
Lft :
CUE :

Provisional diagnosis :

ACUTE RENAL FAILURE with HTN

Treatment : 

1)INJ LASIX 40 mg IV/BD

2)INJ PAN 40 mg IV /OD

3)INJ ZOFER 4mg IV /SOS 

4)INJ ERYTHROPOIETIN 5000 IV S/C ONCE WEEKLY 

5)TAB NICARDIA 10mg PO/BD

6)TAB NODOSIS 500mg PO/BD 

7)TAB OROFER -XT PO/OD 

8)TAB MVT PO/OD

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