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Case report
70 yr old male farmer has presented to the OPD with c/o decreased
urine output since 19 days
HOPI
Patient was apparently asymptomatic 19 days ago then he
noticed that his urine output has been decreasing. It is associated with burning
micturition. No H/o Pyuria, dysuria ,pain abdomen, loin pain.
Reddish discolouration of Urine present 4days back
He also Complains of an Episode of Non bilious vomiting 4days back
The patient also reports that 6 days ago he had an episode of dizziness for which he went to a local hospital where he was diagnosed as BPPV and was managed conservatively.
Past History
The patient gives History of Haemodialysis About 10 yrs ago
after He had fever with abdominal distension
He is a K/c/O CVA 15 yrs ago
K/c/o HTN Since 10 yrs initially on T. LOSAR H AND PRESENTLY
ON T.TELMA H PO OD
Not a K/c/o DM , Asthma, TB, Epilepsy, CAD , Thyroid disorders
Personal History
Appetite :- Normal
Diet ,:Mixed
Bowel : regular
Sleep :- Adequate
Addictions :-
Regular Alcoholic stopped 12 yrs ago
Regular smoker - Used to smoke 2-3 beedis per day
Stopped 12 yrs ago
General Examination
Patient is C/c/C
No pallor, icterus, cyanosis, Lymphadenopathy, Pedal
edema
Temp :- 98.5F
Bp :- 170/110mmHg
PR:- 92 bpm
Spo2 :- 99 % @RA
CVS :- S1s2+ No murmurs
RS :- BAE+ NVBS +
PA:- Soft NT
CNS :- NFND
Haemogram: hb: 9.4mg/dl
lymphopenia, PCV decreased, mch, mcv, RBC count decreased
Blood urea: 55mg/dl (normal= 17-50mg/dl)
Serum Creatinine: 1.8 mg/dl (normal = 0.8-1.3mg/dl)
Serum electrolytes:
Sodium: 122mg/dl (normal = 136-145mEq/l
chloride: 90mg/dl (normal = 98-107mEq/l
Spot urine sample:
Urine protein: 8mg/dl
Urine creatinine: 15mg/dl
Ratio : 0.53
ECG:
Chest X-ray PA view:
USG abdomen and pelvis:
Grade 3 prostatomegaly
Rt kidney grade 2 rpd changes
Lt kidney grade 1 rpd changes
Moderate rt side pleural effusion and collapse of rt lower lobe
USG Chest:
Lt lung normal
Rt lung shows moderate pleural effusion with air bronchogram and collapse of lower zones
Diagnosis: Post renal Acute kidney injury due to protatomegaly and rt sided pleural effusion
Pleural fluid examination:
Under aseptic conditions under USG guidance and 2% lignocaine instilled and 20cc syringe placed in 6th intercostal space in rt interscapular area and 20ml straw colored fluid is aspirated
Pleural fluid LDH: 486IU/L (normal:230-460IU/L)
Pleural sugar: 80mg/dl (normal: 60-90mg/dl)
Pleural protein: 4g/dl (normal: 0-2.5mg/dl)
pleural fluid cytology:
cytosmear shows predominantly lymphocytes and no malignant cells
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