c/o decreased urine output since 3 hrs , c/o breathless since 3 hrs

This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.



This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan



The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

Cheif complaints:
C/o decreased urine output since 3 hours
Breathlessness since 3 hours

Patient was apparently asymptomatic 3 hours back, then developed decreased urine output which is sudden in onset, associated  with breathlessness
H/o abdominal distension and facial puffiness on and off since 3 months
No  h/o fever , chest pain, palpitations cough cold
Past history:
K/c/o HTN since one year on ramipril 2.5 mg+ metoprolol 25 mg
K/c/o CAD , PCI stenting was done 1 year back
Not a k/c/o  dm/ asthama, epilepsy
K/c/o hypothyroid since 6 months, using T.thyronorm 12.5 mcg
There is congenitally externally rotated left leg where he is using stick to walk
General examination: 
Pt is c/c/c moderately nourished and built
Bp : 100/70mmhg
Pr: 74bpm
Rr: 17
Grbs : 130mg/ dl
Cvs : s1 s2 heard
Rs : nvbs , 
Cns : no fnd
Cns tone    RT.               LT
             Ul.  N.                 N
             Ll.  Reduced   Reduced
 
Power        RT    LT

            UL. 5/5  5/5
            LL. 5/5
Reflex:
            B  +3 +3    
            T  +3 +3
             S  +3 +3
             K  +3  not elicited    
             A  +3 not elicited 
             P F 
P/a : soft non tender
Provisional diagnosis:
Acute retention of urine  secondary to ? Sticture urethra
S/p PTCA 1 year  back , hypothyroidism

Treatment:
Inj.ceftraixone 2mg iv bd
Inj.lasix 29 mg  iv /bd
Tab .Ramipril 2.5 + metoprolol 25 mg od
T.ecosprin av 75/10 OD
T. Thyronorm 12.5 mcg OD
neb. with duolin 8th hourly,budecort 12th hrly

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