40yr old male with decreased urine output

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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. is an 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. 

Patient was asymptomatic 5 yrs back . He developed high blood pressure 5yrs ago and was on antihypertensives since then .

6 months back he complained of headache , vomitings and anorexia and went to local hospital and was incidentally diagnosed with renal failure and was advised of dialysis 

Since then he was on hemodialysis 2 times per week 

Recently he came to the opd with complaint of decreased urine output since 20 days . He underwent dialysis 4 times since admission. 

PAST HISTORY

- Known case of hypertension since 5 yrs 

- No h/o diabetes , asthma , tuberculosis , epilepsy 

- History of hip surgery in the past 

FAMILY HISTORY

- history of diabetes and hypertension in parents and siblings

PERSONAL HISTORY 

 Diet is mixed 

Appetite decreased

Urine output decreased 

Bowel movements are regular

Sleep adequate

No addictions

GENERAL EXAMINATION

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

He is well built and moderately nourished 

Pallor - present 

No signs of icterus, edema , lymphadenopathy, clubbing 

VITALS 

PR : 70 bpm 

RR : 18 cpm 

BP : 110/80 

Temp : afebrile 

SYSTEMIC EXAMINATION

Respiratory system

Inspection: 

Chest shape normal

Breath movements -abdominal thoracic

Symmetrical chest movements seen 

Dysponea - absent 

Trachea central

No engorged veins or sinuses seen 

Palpation

 Trachea -central 

Measurement of chest expansion - symmetrical 

Tactile vocal fremitus normal 

Percussion 

Resonant note is heard

Auscultation

Normal Vesicular breath sounds heard.

CARDIOVASCULAR SYSTEM

Inspection 

No dilated veins and sinuses

No precordial bulge is seen 

Palpation 

Apical impulse felt 

Percussion 

Right and left border of heart are percussed 

Auscultation

S1 ,S2 heard , no murmurs 

ABDOMEN 

Inspection

Shape of the abdomen - scaphoid 

Umbilicus inverted 

No engorged veins , sinuses

No hernial orifices 

Palpation

No local rise of temperature and no tenderness 

No organomegaly 

Auscultation - bowel sounds are heard 

CENTRAL NERVOUS SYSTEM

No focal neurological defecit 

INVESTIGATIONS

USG 

Provisional diagnosis

Chronic kidney disease with maintanence hemodialysis 

TREATMENT

Tab shelcal 500mg 

Tab Pth 30 

Tab orofer 

Tab ultracet 10 

Inj Epo 

Inj iron sucrose 

Tab Alprax 0.25mg