45 Year Old Male with Decreased Urine Output
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Here's a case that I have seen -
45 year old labourer from Nakrekal presented with the chief complaints of pain in the throat and difficulty in swallowing since 1 day for both liquids and solids. H/O change in the voice present.
There is H/O expectoration since 1 day. It is non-purulent, non-blood stained in nature, associated with cough.
H/O loss of appetite since 3 days due to pain in the throat
H/O decreased urine output since 1 day.
H/O burning mucturition, pain during micturition since 1 day.
There is no H/O fever, weight loss, sweating.
There is no H/O pedal oedema, shortness of breath.
Past History -
Not a K/C/O HTN, DM, Asthma, TB, Cardiac and Thyroid Anomalies
Regular intake of Alcohol since 20 years.
O/E Patient was C/C/C
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema
Vitals -
Temperature - Afebrile
BP - 110/70 mmHg
PR - 72 BPM Regular
RR - 18 CPM
GRBS - 129 mg/dl
SPO2 - 98% on RA
Local Examination of the Oral cavity -
Trismus - Present, Grade II
Painful mouth opening - Present
Lips - Pale. Diffuse whitish plaque was noted over the oral mucosa, lips with erosion
Anterior 2/3rd of tongue, floor of mouth and buccal Mucosa - Coated and Loss of papillae present.
Hard palate - Congested
Oropharynx - Mucosal erosions seen on the posterior pharyngeal wall
CVS - S1, S2 heard. No murmurs
RS - BLAE +, NBVS heard
P/A - Soft, Non-tender. NAD
CNS - NAD
Diagnosis -
1. Acute on Chronic Renal Failure
2. (?) Mucositis
3. Oral
Treatment Given-
1. IV Fluids - NS/RL
2. Inj. Lasix 40mg IV BD
3. Tab. Fluconazole 150mg/PO/STAT
4. Candid Mouth Paint LA/Thrice a day
5. Zylee gel for LA/TID
6. Tab. Pregabalin 75mg/PO/HS
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