63 year old male with abdominal distention, lowerlimb swelling, Constipation
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A 63 years old male resident of yadadhri presented to the OPD with
CHIEF COMPLAINTS :
Burning micturition since 4 month
Reddish urine since 4 months
Abdominal distention since 1 month
Bilateral lower limb swelling from 10 days
Not passed stools since 4 days
HISTORY OF PRESENT ILLNESS :
- Patient was apparently normal 11 years ago
- He developed Right knee pain following which he was diagnosed with ? Hematoma surgery was done ( No documents )
- 10 years back his elder son has financial mess with him under alcohol influence fought with him and he fell on rocks and had a spine injury following which he had weakness of all four limbs and urinary incontinence, Unable to walk following two months later with conservative management with egg and fish he regained his power gradually, initially able to work with support later able to do his daily routine activities including farming
- Four years back patient developed gradual decrease in urine output and retention with abdominal discomfort and SOB when he was diagnosed with ? BPH /obstructive uropathy unknown surgical procedure was done (no documents available) for next two years he does not have any symptoms but thereafter he again developed thin stream of urine so he was put on foleys for 2 years changing at every 7 to 10 days.
- 1 year back H/o similar complaints of sudden weakness of all limbs and spontaneous recovery in 2-3 months
- Since 4 months body weakness, burning micturition, reddish urine
- Since 1 month abdominal distention
- Bilateral lowerlimb edema since 10 days ( pitting type )
- Not passed stools from 4 days but passing flatus
PAST HISTORY :
Diabetes - No
Hypertension - Present
Diagnosed at around 2 years ago
But no medication taken
TB - No
Asthma - No
Epilepsy - No
CVD - No
Chemo/Radiation Exposure - No
Surgical history -
Surgery for hematoma at knee
? BPH / obstructive uropathy surgery
FAMILY HISTORY : Nil significant
PERSONEL HISTORY :
Diet - Mixed
Appetite - Decreased
Bowel and bladder -
No stools since 4 days
Allergies - No
Addictions - Occasional alcohol consumption 90 ml
- Stopped smoking 10 years ago
GENERAL EXAMINATION :
Temperature - Afebrile
Pulse - 80 beats/min
BP - 190/100 mmHg
RR - 20 cycles/min
GRBS - 108 mg%
SPO2 - 99 %
Pallor - Yes
Icterus - No
Clubbing - No
Cyanosis - No
Lymphadenopathy - No
SYSTEMIC EXAMINATION :
CVS :
No thrills
No murmurs
S1 and S2 heard
RESPIRATORY SYSTEM :
Position of trachea - Central
No Dyspnoea , Wheeze
Breath Sounds - vesicular
BAE - +ve
ABDOMEN :
Shape - Distended
Gross free fluid with slit like umbilicus
No tenderness, palpable mass
Bowel sounds heard
Liver and Spleen not palpable
Hernial orifices normal.
Per Rectal examination :
No Anal tugs / fissures / fistula
Hard stool pellets +
Anal tone loss
No mass palpable
Prostatomegaly +
No blood staining noted
CNS :
Conscious
Speech: Slurred since 4 days
Glasgow scale: E4V5M6
Tone:
UL - Decreased
LL - Decreased
Power :
UL- 2/5 3/5
LL - 3/5 3/5
REFLEXES : Right Left
Biceps - +
Triceps + +
Supinator - +
Knee - +
Ankle - +
Plantars + +
INVESTIGATIONS :
11/8/22 -
12/8/22 -
13/8/22 -
14/8/22 -
15/8/22 -
16/8/22 -
PROVISIONAL DIAGNOSIS :
CHRONIC RENAL FAILURE WITH QUADREPARESIS SECONDARY TO COMPRESSIVE MYELOPATHY
TREATMENT :
11/8/22 -
Inj Lasix 40mg/IV/TID
Inj Pan 40mg/IV/OD
Inj Optineuron 1 amp in 100 ml NS/IV/OD
Tab Nodosis 500mg/PO/BD
Tab Orofer-XT /PO/OD
Tab Ecosprin- AV 75/10 mg/OD/HS
Salt and fluid restriction
BP/PR/Temp 4rth hrly monitoring.
12/8/22 :
Pt - c/c/c
Temp 98.6 F
PR - 84 bpm
BP - 160/90 mmHg
RS - Bilateral air entry present and clear
CVS - S1 & S2 are heard
GRBS 84 mg/dl
P/A soft & distended
CNS
Motor- Rt Lt
Tone. UL Increased increased
LL. Decrease. Decreased
Power:
UL. 1/5. 3/5
LL . 2/5 2/5
3.Reflexes
B T K A
R - +2 - -
L +2 +2 +2 +
Stools passed
Input /output - 600 /500 ml
1. Inj. LASIX 40 mg /IV/TID
2. Inj. PAN 40 mg /IV/ OD
3.Inj. ZOFER 4 mg / IV/SOS
4. Inj. OPTINEURON 1 amp in 100 ml NS/IV/OD
5. Tab. NODOSIS 500 MG /PO/BD
6.Tab. OROFER XT /PO /OD
7. Tab. SHELCAL 500 mg/PO/OD
8.Tab. ECOSPRIN AV 75 /10 mg /OD/HS
9.Salt & fluid restriction
10. propped up position
11.BP/PR/Temp 4th hourly monitoring
12.strict I/O charting
13/8/22 -
Pt - c/c/c
PR - 80 bpm
BP - 150/80 mmHg
RS - Bilateral air entry present
CVS - S1 & S2 are heard
GRBS 84 mg/dl
P/A soft & distended
CNS
Motor- Rt. Lt
1. Tone:. UL Increased increased
LL. Decrease. Decreased
2. Power.
UL. 1/5. 3/5
LL . 2/5 2/5
3.Reflexes
B T K A
R - +2 - -
L +2 +2 +2 +
1. Inj. LASIX 40 mg /IV/TID if BP >110 mmHg
2. Inj. PAN 40 mg /IV/ OD
3.Inj. ZOFER 4 mg / IV/SOS
4. Inj. OPTINEURON 1 amp in 100 ml NS/IV/OD
5. Tab. NODOSIS 500 MG /PO/BD
6.Tab. OROFER XT /PO /OD
7. Tab. SHELCAL 500 mg/PO/OD
8.Tab. ECOSPRIN AV 75 /10 mg /OD/PO
9.Salt & fluid restriction
10. propped up position
11.BP/PR/Temp 4th hourly monitoring
12.strict I/O charting
14/8/22 -
Pt - c/c/c
PR - 83 bpm
BP - 160/90 mmHg
RS - Bilateral air entry present
SpO2 99 %
CVS - S1 & S2 are heard
P/A -soft & distended
CNS
Motor- Rt. Lt
Tone. UL Increased increased
LL. Decrease. Decreased
2. Power.
UL. 1/5. 3/5
LL . 2/5. 2/5
3.Reflexes
B T K A P
R - +2 - -
L +2 +2 +2 +
Input/output - 1050 /1700 ml
stools not passed since 2 days
Flatus not passed since 2 days
1. Inj. LASIX 40 mg /IV/TID if BP >110 mmHg
2. Inj. PAN 40 mg /IV/ OD
3.Inj. ZOFER 4 mg / IV/SOS
4. Inj. OPTINEURON 1 amp in 100 ml NS/IV/OD
5. Tab. NODOSIS 500 MG /PO/BD
6.Tab. OROFER XT /PO /OD
7. Tab. SHELCAL 500 mg/PO/OD
8.Tab. ECOSPRIN AV 75 /10 mg /OD/PO
9.Salt & fluid restriction
10. propped up position
11.BP/PR/Temp 4th hourly monitoring
12.strict I/O charting
13.Tab. CILACAR 10 mg /PO/OD
15/8/22 :
Pt - c/c/c
Temp - 98 F
PR - 72 bpm
BP - 160/100 mmHg
RS - Bilateral air entry presenT
RR - 16 cpm
CVS - S1 & S2 are heard
P/A soft & distended
CNS
Motor- Rt. Lt
Tone. UL Increased increased
LL. Decrease. Decreased
2. Power.
UL. 1/5. 3/5
LL . 2/5 2/5
3.Reflexes
B T K A
R - +2 - -
L +2 +2 +2 +
ENEMA GIVEN PREVIOUS DAY
1. Inj. LASIX 40 mg /IV/TID if BP >110 mmHg
2. Inj. PAN 40 mg /IV/ OD
3.Inj. ZOFER 4 mg / IV/SOS
4. Inj. OPTINEURON 1 amp in 100 ml NS/IV/OD
5. Tab. NODOSIS 500 MG /PO/BD
6.Tab. OROFER XT /PO /OD
7. Tab. SHELCAL 500 mg/PO/OD
8.Tab. ECOSPRIN AV 75 /10 mg /OD/PO
9.Salt & fluid restriction
10. propped up position
11.BP/PR/Temp 4th hourly monitoring
12.strict I/O charting
13.Tab. CILACAR 10 mg /PO/OD
14.Syp. LACTULOSE 20 ml/PO/BD
SOAP WATER ENEMA
16/8/22 :
Pt - c/c/c
Temp Afebrile
PR - 72 bpm
BP - 150/100 mmHg
RS - Bilateral air entry present
RR - 16 cpm
CVS - S1 & S2 are heard
P/A soft & distended
CNS
Motor- Rt. Lt
Tone. . UL Increased increased
LL. Decrease. Decreased
2. Power.
UL. 1/5. 3/5
LL . 2/5 2/5
3.Reflexes
B T K A P
R - +2 - -
L +2 +2 +2 +
1. Inj. LASIX 40 mg /IV/TID if BP >110 mmHg
2. Inj. PAN 40 mg /IV/ OD
3.Inj. ZOFER 4 mg / IV/SOS
4. Inj. OPTINEURON 1 amp in 100 ml NS/IV/OD
5. Tab. NODOSIS 500 MG /PO/BD
6.Tab. OROFER XT /PO /OD
7. Tab. SHELCAL 500 mg/PO/OD
8.Tab. ECOSPRIN AV 75 /10 mg /OD/PO
9.Salt & fluid restriction
10. propped up position
11.BP/PR/Temp 4th hourly monitoring
12.strict I/O charting
13.Tab. CILACAR 10 mg /PO/OD
14.Syp. LACTULOSE 20 ml/PO/BD
17/8/22 :
Pt - c/c/c
Temp Afebrile
PR - 72 bpm
BP - 150/100 mmHg
RS - Bilateral air entry present
RR - 16 cpm
CVS - S1 & S2 are heard
P/A soft & distended
CNS
Motor-. Rt. Lt
Tone : UL Increased. Increased
LL. Decreased Decreased
2. Power.
UL. 1/5. 3/5
LL . 2/5 2/5
3.Reflexes
B T K A P
R - +2 - -
L +2 +2 +2 +
1. Inj. LASIX 40 mg /IV/TID if BP >110 mmHg
2.Inj. ZOFER 4 mg / IV/SOS
3.Inj RANTAC 50 mg IV /BD
4. Inj. OPTINEURON 1 amp in 100 ml NS/IV/OD
5. Tab. NODOSIS 500 MG /PO/BD
6.Tab. OROFER XT /PO /OD
7. Tab. SHELCAL 500 mg/PO/OD
8.Tab. ECOSPRIN AV 75 /10 mg /OD/PO
9.Salt & fluid restriction
10. propped up position
11.BP/PR/Temp 4th hourly monitoring
12.strict I/O charting
13.Tab. CILACAR 10 mg /PO/OD
14.Syp. LACTULOSE 20 ml/PO/BD
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