A 70 year old man came to the OPD 2 days ago with complaints of anuria and shortness of breath.


The patient's and his attender's consent was obtained, following which detailed history was taken and examination was performed.

HOPI

The patient was apparently asymptomatic 20 days ago when he developed swelling in the feet which progressively extended to his knees. On 8th October, he didn't pass urine for the entire duration of the day and was brought to the OPD for the same reason. He also had weakness and shortness of breath. 

At the time of examination, the patient was restless and unable to lie on his back for more than a few minutes. Productive cough was also noted.

Past Illnesses

Two years ago, the patient was in a road traffic accident where he fell from his bike near his village in Nalgonda. He fractured his left leg near his hip and underwent a surgical procedure where rod(s) were inserted to ensure proper healing. He has been unable to work ever since and has become bedridden.
He is unable to walk or sit on his own. 
He has been taking painkillers (NSAIDs) for hip pain since the past 6 months. 
He has history of diabetes since 10-15 years for which he is taking medication (Metformin 500 mg once daily) issued by the Government.
No history of Hypertension, asthma, epilepsy or TB.

Family history

No relevant family history. 
He was married 45 years ago and has four children.

Personal history

Appetite has reduced in the past few days. Mixed type of diet. Sleep is adequate except the past two days. Normal bowel movements. Anuria was present two days ago.

He had a habit of consuming bidi since childhood. He would complete one stack in 2 days. However, he claims to have stopped consuming bidi 2 years ago.

He also used to consume 1 liter of toddy everyday since he was 18 which he stopped 2 years ago.

General examination

The patient was conscious, coherent and well oriented to time and space at the time of examination. 
The patient is moderately built and moderately nourished.
Pallor, icterus, clubbing, cyanosis and lymphadenopathy are absent. 
Edema in the feet is still present (non-pitting).
Koilonychia is absent. 










Vitals 

Pulse rate: 97/min
Afebrile to touch.
Respiratory rate 28/min
BP: 140/90 mm of Hg
O2 saturation 98% (with O2 therapy)

Systemic examination

CVS

Cardiac sounds S1 and S2 present.
No thrills or murmurs.
Apex beat not heard.

Respiratory system

Chest is symmetrical, barrel shaped on inspection.
No visible deviation of the trachea, supraclavicular hollowing or unilateral sternocleidomastoid prominence.
No drooping of either shoulder.
There appears to be a retraction near the 7th intercoastal space on both sides.

On palpation, inspectory findings were confirmed. Trachea in midline, no intercoastal crowding, no rosary beads appearance at costochondral junctions. Pain is present at the site of retraction in the 7th intercoastal space. No dilated veins. Chest movements were normal, symmetrical. Tactile fremitus was more apparent on the right side.

On percussion, no dullness or abnormality was noted.

On auscultation, Bilateral crepts were present and wheezing was noted.

CNS

The patient is conscious, drowsy.
Speech is normal.
No neck stiffness. Kernig's sign is absent.

Abdomen

Normal shape. No tenderness.
No palpable mass. Liver and spleen not palpable. 



Investigations

Sputum for AFB ? 
2D Echo ?
RFT,ECG,ABG :











aPTT : 43 sec ( Normal : 24-33 sec)

         PT : 22 sec ( Normal : 10-16 sec)


Provisional diagnosis:

Acute exacerbation of COPD? , Acute kidney injury (AKI)? Renal failure? HF?

Treatment

Inj. LASIX 40 mg IV BD
Nebulization with Duolin and Budecort stat
Inj. Hydrocort 100 mg IV stat
Oxygen inhalation 10 liters
25% Dextrose IV stat
RBS monitoring  (2 hourly)
Strict monitoring of SPO2, RR, PR, BP (3 hourly)
Syrup Ascoryl-LS 10 ml
Inj. Pantoprazole 40 mg IV 













 



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