A 78/M WITH ABDOMINAL PAIN AND REDUCED URINE OUTPUT

March 08, 2022

A 78/M WITH ABDOMINAL PAIN AND REDUCED URINE OUTPUT

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Chief complaints

Pain abdomen since 2 days

Reduced urine output since 1 day

History of presenting Illness

Patient was apparently asymptomatic 2 days ago then developed pain in right HYPOCHONDRIUM, insidious onset, gradually progressive not associated with vomitings and not relieved by bending forward position

No history of fever, loose stools, chest pain, palpitations

From 1 day patient is having decreased urine output not associated with burning micturition

Past history

PTCA 10 yrs back 

Left-sided hearing loss in 6 years and patient is using hearing aid

Not a known case of diabetes, hypertension, asthma, tuberculosis, epilepsy

Treatment history

Patient is on 

1. T. Torsemide 10 mg PO OD

2. T. Isosorbide dinitrite + hydralazine 20/37.5mg PO BD

3. T. Atorvas/clopidogrel 75mg PO HS

VITALS - 

TEMPERATURE - 99.1

PULSE RATE - 87 BPM

BLOOD PRESSURE - 130/80 MM OF HG 

RESPIRATORY RATE - 30

SPO2 - 97 % AT ROOM AIR

General examination

Patient is conscious coherent cooperative well oriented to time place and person

Pallor present

No Icterus, cyanosis, clubbing, lymphoadenopathy 

SYSTEMIC EXAMINATION - 

PER ABDOMEN : DISTENDED, umbilicus inverted SOFT,  TENDER in Rt iliac fossa, Rt lumbar, rt HYPOCHONDRIUM

CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT, decreased breath sounds - Rt ISA, IAA, IMA, Fine crepitations Lt ISA, MSA

CENTRAL NERVOUS SYSTEM : NAD

HEMOGRAM

HB 11.9

TC 17,100

PLT 1.88

MCV 86.8

PCV 35.5

MCH 29.5

MCHC 34

SMEAR - NORMOCYTIC NORMOCHROMIC

BGT

A POSITIVE

RFT

Urea 47

Creatinine 2.2

S. Sodium  139

S. Potassium  3.8

S. Chloride 97

Urine chloride 142

Urine sodium 185

Urine potassium 23

Urine protein/creatinine ratio 0.11

S. Amylase 41

S. Lipase 28

CUE 

Albumin: trace

Sugar: nil

Pus cells: 2-3

Epithelial cells: 2-3

LFT

TB 1.86

DB 0.94

AST 32

ALT 20

ALP 115

TP 5.7

ALB 3.6

Ultrasound abdomen

Echo of multiple anechoic cyst is noted in both kidneys largest 5.2 X 2.4 cm and the right kidney and 5 X 4.8 CM in the left kidney

Impression:-

Bilateral grade 1 rpd with simple renal cortical cyst

Grade 1 fatty liver

Chest X ray

X ray erect abdomen

ECG

ABG

Diagnosis

Acute pancreatitis 

with AKI ON CKD 

WITH post PTCA (10 yr back)

With Left side hearing loss

Treatment

IVF NS/RL at 50 ml/hr

Inj. Tramadol 1 AMP in 100ml NS IV BD

Inj. Ceftriaxone 1g IV BD

SOAP NOTED DAY 2

ICU bed 2

SOAP NOTES DAY 2

S

C/O abdominal pain decreased

O

VITALS - 

Temp - 99.1

PR - 107 BPM

BP - 130/80 MM OF HG 

RR - 20

SPO2 - 99% AT ROOM AIR

GE:-

Patient is conscious coherent cooperative well oriented to time place and person

Pallor +

No Ictrus, cyanosis, clubbing, lymphoadenopathy

SYSTEMIC EXAMINATION - 

PA : DISTENDED, unblicus inverted SOFT, TENDER in Rt lumbar, rt HYPOCHONDRIUM

CVS : S1 AND S2 HEARD , NO MURMURS

RS : BILATERAL AIR ENTRY PRESENT, decreased breath sounds - Rt IAA, IMA

CNS : NAD

HEMOGRAM

HB 10.9

TC 6,400

PLT 1.25

MCV 81.6

SMEAR - NORMOCYTIC NORMOCHROMIC, with mild thrombocytopenia

RFT

Urea 78

Creatinine 2.5

A

HFrEF (EF-34%) 

Peripheral vascular disease with cor pulmonale with k/c/o CAD s/p PTCA(10years back) with CKD on conservative management with left sided hearing loss (on hearing aid since 6 years) ?congestive hepatopathy. 

P:- 

Inj. Lasix 40mg IV SOS if SBP >130MMHG

T. Ecosprin AV 75/10 mg PO HS

T. Met-XL 25 MG PO OD

T. Nodosis 500 mg PO BD

T. Orofer XT PO OD

T. Shelcal 500 mg PO OD

Intermittent CPAP

Inj. Ceftriaxone 1g IV BD (day 3)

Outside ultrasound abdomen-

Surgery referral:-

Chest X ray

Ultrasound abdomen in our hospital:-

Gall bladder:- Distended, wall thickness measuring 4mm

Appendix- not visualised 

Evidence of mild free fluid in abdomen- minimal ascites.

ICU bed 2

SOAP NOTES DAY 3

S

C/O abdominal pain decreased

O

VITALS - 

Temp - 98.5

PR - 96 BPM

BP - 100/80 MM OF HG 

RR - 22

SPO2 - 100% @5 lits O2

GE

Patient is conscious coherent cooperative well oriented to time place and person

Pallor +

No Icterus, cyanosis, clubbing, lymphoadenopathy

SYSTEMIC EXAMINATION - 

PA : DISTENDED, umblicus inverted SOFT, tenderness decreased in Rt lumbar, Right hypochondrium

CVS : S1 AND S2 HEARD , NO MURMURS

RS : BILATERAL AIR ENTRY PRESENT, decreased breath sounds - Rt IAA, IMA

CNS : NAD

HEMOGRAM

HB 10.7

TC 12,600

PLT 1.60

MCV 85

SMEAR - NORMOCYTIC NORMOCHROMIC Anemia with neutrophilic leucocytosis

RFT

Urea 90

Creatinine 2.6

A

HFrEF (EF-34%) 

Peripheral vascular disease with cor pulmonale with k/c/o CAD s/p PTCA(10years back) with CKD on conservative management with left sided hearing loss (on hearing aid since 6 years) ?congestive hepatopathy. 

P:- 

Inj. Lasix 40mg IV SOS if SBP >130MMHG

T. Ecosprin AV 75/10 mg PO HS

T. Met-XL 25 MG PO OD

T. Nodosis 500 mg PO BD

T. Orofer XT PO OD

T. Shelcal 500 mg PO OD

Intermittent CPAP

Inj. Ceftriaxone 1g IV BD (day 3)

	Day1	Day2	Day3
TLC	17,100	6,400	12,600
Sr. UREA	47	78	90
Sr. Creatinine	2.2	2.5	2.6

USG chest done :-

Impression -

Minimal right pleural effusion

Review ultrasound Abdomen and pelvis done:- 

Impression- 

Features s/o Acute acalculus cholecystitis.

B/L Renal cortical cysts 

Minimal ascites 

ICU bed 2

SOAP NOTES DAY 4

S

C/O abdominal pain decreased

O

VITALS - 

Temp - 98.5

PR - 96 BPM

BP - 110/80 MM OF HG 

RR - 22

SPO2 - 100% @5 lits O2

GE

Patient is conscious coherent cooperative well oriented to time place and person

Pallor +

No Icterus, cyanosis, clubbing, lymphoadenopathy

SYSTEMIC EXAMINATION - 

PA : DISTENDED, umblicus inverted SOFT, tenderness decreased in Rt lumbar, Right hypochondrium

CVS : S1 AND S2 HEARD , NO MURMURS

RS : BILATERAL AIR ENTRY PRESENT, decreased breath sounds - Rt IAA, IMA

CNS : NAD

HEMOGRAM

HB 11.5

TC 16,400

PLT 1.50

MCV 85

SMEAR - NORMOCYTIC NORMOCHROMIC Anemia

RFT

Urea 91

Creatinine 2.5

ECG at 9am- ventricular trigeminy

	Day1	Day2	Day3	Day4
TLC	17,100	6,400	12,600	16,400
Sr. UREA	47	78	90	91
Sr. Creatinine	2.2	2.5	2.6	2.5

A

HFrEF (EF-34%) 

Peripheral vascular disease with cor pulmonale with k/c/o CAD s/p PTCA(10years back) with CKD on conservative management with left sided   hearing loss (on hearing aid since 6 years) with Acute acalculus cholecystitis

P:- 

Inj. Lasix 40mg IV SOS if SBP >130MMHG

T. Ecosprin AV 75/10 mg PO HS

T. Met-XL 25 MG PO OD

T. Nodosis 500 mg PO BD

T. Orofer XT PO OD

T. Shelcal 500 mg PO OD

Intermittent CPAP

Inj. Ceftriaxone 1g IV BD (day 4)

https://sravanivv180.blogspot.com/2022/03/78-year-old-male-with-abdominal-pain.html

ICU bed 2

SOAP NOTES DAY 5

S

C/O abdominal pain and tenderness present in right hypochondrium

O

VITALS - 

Temp - 98.1

PR - 79 BPM

BP - 110/70 MM OF HG 

RR - 22

SPO2 - 100% @5 lits O2

GE

Patient is conscious coherent cooperative well oriented to time place and person

Pallor +

No Icterus, cyanosis, clubbing, lymphoadenopathy

SYSTEMIC EXAMINATION - 

PA : DISTENDED, umblicus inverted SOFT, tenderness present in Rt lumbar, Right hypochondrium, Bowel sounds present. Stools passed . No fever spikes

CVS : S1 AND S2 HEARD , NO MURMURS

RS : BILATERAL AIR ENTRY PRESENT, decreased breath sounds - Rt IAA, IMA

CNS : NAD

HEMOGRAM

HB 11.5

TC 14,600

PLT 1.54

MCV 83.8

SMEAR - NORMOCYTIC NORMOCHROMIC Anemia with leukocytosis.

RFT

Urea 90

Creatinine 2.2

	Day1	Day2	Day3	Day4	Day 5
TLC	17,100	6,400	12,600	16,400	14,600
Sr. UREA	47	78	90	91	90
Sr. Creatinine	2.2	2.5	2.6	2.5	2.2

A

HFrEF (EF-34%) 

Peripheral vascular disease with cor pulmonale with k/c/o CAD s/p PTCA(10years back) with CKD on conservative management with left sided   hearing loss (on hearing aid since 6 years) with acute acalculus cholecystitis.

P:- 

Propped up position

Fluid and salt restriction

Inj. Lasix 40mg IV TID 8am--2pm--8pm

T. Ecosprin AV 75/10 mg PO HS

T. Met-XL 25 MG PO BD

T. Nodosis 500 mg PO SOS

T. Livogen 1 tab PO OD

T. Shelcal 500 mg PO BD

Inj. Tramadol 1 amp in 100 ml NS IV TID

Intermittent CPAP

Inj. Ceftriaxone 1g IV BD(Day 5)

Inj. Thiamine 1amp in 50 ml NS IV OD