CKD PATIENT CASE 2

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36 year old male, cement worker by occupation,  came to Medicine OPD with complaints of : 

.

 Chief complaints

-Pain in lower abdomen at right loin region 

Since 5 days

History of present illness

Patient was apparently asymptomatic l year back, then he developed pain in abdomen and went to hospital and diagnosed of post renal caliculi for which he took medical treatment and got relieved.

Recently he again came to opd with pain in the right loin region in abdomen since 5 days

He started pain abdomen 5 days back to which he went to local hospital and took medication, but the pain is not relieved and associated with decreased urine out put and abdominal distention

Daily routine

Wakes up at 6am 

breakfast - 7.30

Goes to factory- 8am

1pm - lunch

4.30pm- tea

6pm - home

8pm - dinner

Alcohol- 2 times a week, 180 ml. Since past 15 years

Past history

No history of fever

No history of vomiting

No history of loose stools

No history of past surgeries

no history of hypertension,diabetes, etc

Family history

His family members are not having any relauent issues

Personal history

Occupation is cement factory worker

Sleep is adequate

Diet is mixed

bladder is normal

No allergies

Regular alcohol consumption since 15 years 

Family history 

Not significant 

General examination

Patient is conscious, coherent and co-operative.

Examined in a well lit room.

Moderately built and nourished

Icterus - present (sclera)

Pedal edema - absent              

No pallor, cyanosis, clubbing , lymphadenopathy .

Vitals : 

Temperature- afebrile

Respiratory rate - 28 cpm

Pulse rate - 76 bpm 

BP - 120/80 mm Hg.

Spo2 at room air is 98%

SYSTEMIC EXAMINATION: 

CVS : S1 S2 heard, no murmurs

Respiratory system : normal vesicular breath sounds heard.

Abdominal examination: 

INSPECTION : 

      Shape of abdomen- distended

-No tenderness of abdomen 

• Umblicus - normal
• Movements of abdominal wall - moves with respiration 
• Skin is smooth and shiny;
• No scars, sinuses, distended veins, striae

PALPATION : 

No Local rise of temperature

Tenderness absent

Guarding present

Rigidity absent 

hernial orifices normal

Fluid thrill absent

Liver not palpable .

Spleen not palpable 

Kidneys not palpable 

Lymph nodes not palpable 

PV examination -normal 

P/R examination -normal 

.

CNS EXAMINATION: 

Conscious 

Speech normal

No signs of meningeal irritation 

Cranial nerves: normal

Sensory system: normal

Motor system: normal

Reflexes:      Right.           Left. 

Biceps.         ++.                 ++

Triceps.         ++.                 ++

Supinator      ++.                  ++

Knee.              ++.                 ++

Ankle              ++.                  ++

Gait: normal

Investigations

Serology: 

HIV - negative 

HCV - negative 

HBsAg - negative 

Provisional diagnosis

Post renal acute kidney injury secondary to ureteric calculus associated with urosepsis and acute pancreatitis 

Treatment

Injection  Piptaz - iv (TID)

Tab udiliv - 300 mg bd

inj vit k

inj lasix

Tab Rantac - 150 mg od

inj tramadol 4mg td