Medicine practical examination SHORT CASE ,Hall ticket number:1701006056

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HALL TICKET NUMBER:1701006056
case:
80 year old male ,who is agricultural worker came with chief complaints of
-Fever from 4 days
-Vomiting from 2 days 
-Decreased urine output from 2days
History of presenting illness:
The patient was apparently asymptomatic
4days back ,then he developed fever which was insidious in onset,gradual in progression associated with chills and rigor and relieved on medication
-One episode of vomiting 2 days ago, which has food as content ,non bilious and non foul smelling .
-Decreased urine output from 2days 
Past history:
-He had similar complaints in past ,10 years ago for which he was given antibiotics 
-He is a know case of hypertension from 24 years
-He has no diabetes,asthma, epilepsy, tuberculosis
-He underwent nephrectomy 24 years ago, which he donated to his brother
Present history:
Appetite-Normal
Diet- mixed
Sleep - adequate
Bowel habits - regular
Bladder habits- oliguria since 2 days, associated with burning micturition
Addiction- 3 beedi/ day from 27yrs of age
-He takes alcoholoccasionally 
-Stopped both alcohol and smoking after  nephrectomy surgery.
General examination:
- The patient was examined in a well lit room after taking consent on proper exposure
- Patient is conscious, coherent, co operative and well oriented to time, place, and person moderately build and nourished.
-pallor and pedal edema is present
- No icterus , cyanosis,clubbing, lymphadenopathy.

Vitals: 
Temperature:99.2F
BP- 150/90 mmHg ( on medication)
Respiratory rate- 18 cpm
Pulse rate - 76 bpm
Systemic examination:
Abdominal examination
Inspection:
-Umbilicus is inverted and central
-All quadrants move equally on respiration
-No abdominal distension seen
-No scars,sinuses, visible pulsations,engorged veins
Palpation:
-Abdomen is soft and non -tender
-No organomegaly seen
Auscultation : Bowel sounds heard
Cardiovascular system:
-   No visible pulsations, scars, engorged veins. 
No rise in jvp 
-   Apex beat is felt at 5 Intercoastal space medial to mid clavicular line.
-  S1 S2 heard . 
-No murmurs.
 Respiratory system
- Shape of chest is elliptical, b/l symmetrical.
- Trachea is central. 
-Expansion of chest is symmetrical
-  Bilateral Airway entry present
-Normal vesicular breath sounds 
Nervous system Examination:
-No signs of meningeal signs
-Cranial nerves: normal
-Sensory system: normal
-Motor system: normal
Investigations.:
Haemogram:
Interpretation:
Hemoglobin - Reduced
Increased WBC count- Raised
Renal function tests:
Interpretation:
Urea - Raised
Creatinine- Raised
Complete urine examination:
     Urine - pus cells (plenty) - urinary tract inflammation
Urea is raised
USG report:
 1)Raised echo genicity of right kidney
2) normal size of kidney
3) mild hydronephrosis
4) not visible left kidney

ECG:


Provisional Diagnosis:
Acute on chronic kidney disease might be due to recurrent urinary track infection.
Treatment:
-Inj. Piptaz -2.25gm/tid
-Tab. Lasix -40ug/po/ bd
-Tab. Zofer -4mg/po/ sos
-Tab. Dolo -650/ po/ sos
-Tab. Pan 40mg /po/ od
-Nebi. Duolin and Budecort 6hrly
-Syr. Mucaine gel 15ml/po/ bd before meal 15min
-Syrup. Cremaffin 15ml/po/ sos.







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