Final practical long case

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A 65 yr old male patient was presented to OPD with no urine passage / anuria past 1 week.

History of past illness:

He had renal calculi past 20 yrs and shortness of breath since 5 days

PATIENT WAS APPARENTLY ASYMPTOMATIC 15 YEARS BACK , PATIENT SUDDENLY FELL FROM TODDY TREE WHILE CLIMBING HAD HISTORY OF FRACTURE OF FEMUR. 

Patient has got restricted neck and knee movements since then.

Past history: 

H/o hypertension is seen past 10yrs and is put on medication since.

No h/0 of dm asthama or any syncopal attack s

 As told by the patient and his attenders

First he had h/o fall from tree 9-10 yrs back, He used to walk with support for few months

Then again he had h/o fall at his home

From then he was unable to walk even with support.

TREATMENT HISTORY : 

FOR HYPERTENSION - TAB.AMPONG 5 MG PO / OD

SURGERY HISTORY:treatment done for renal calculi.

PERSONAL H/O :

APPETITE - decreased

BOWELS - irregular

MICTURITION - abnormal

ADDICTIONS :- 

OCCASIONALLY ALCOHOL CONSUMPTION

History of smoking is present.

FAMILY HISTORY:no significant family History is seen.

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE.

WELL ORIENTED TO TIME,PLACE,PERSON.

SIGNS OF PALLOR AND PEDAL EDEMA PRESENT.

NO CLUBBING

NO ICTERUS

NO LYMPHADENOPATHY.

Vitals:

TEMPERATURE - 98.6 F

PULSE - 100 BPM

RR - 16 CPM

BP - 160/90mmhg

Spo2 - 98 % @ ROOM AIR

Investigation:

Clinical images:

Renal calculi are the findings here

His neck is always in the same position

Doesn't bend forward or backward.

His legs at knee level are always restricted.

Can't bend his legs or flex them straight.

Tablets:

1) Inj. Meropenem 500mg / IV/BD

2) Inj. LASIX 40mg/IV/BD

3 ORAL FLUIDS ~2L.

4) Inj. PAN 40mg /IV/OD

5) Neb with DUOLIN & Budecort 8th hourly

6) Tab. AMLONG 5mg .