Clinical Case Summary: 66-Year-Old Male Patient

A 66-year-old male with a history of DM, HPT, CKD (on dialysis), hyperlipidaemia, and prior amputation presented via ER with confusion, weakness, laboured breathing, tachycardia, and a history of head trauma. Initial diagnostics revealed sinus tachycardia, septal myocardial infarction, cardiomegaly, lung consolidation, and pleural effusion. CT brain showed progressive brain involution but no acute trauma or stroke.

Throughout the admission, the patient remained consistently anuric, required regular haemodialysis (HD), and experienced recurring episodes of confusion and fluctuating GCS levels. The patient has been treated with continuous IV antibiotics (Meronem, Tygacil) and supportive medication for pain and renal health. Inflammatory markers (CRP) remained elevated throughout the stay.

As of mid-July 2026, the patient continued to receive hemodialysis and physiotherapy. Recent diagnostic imaging (15/07/26) indicated a stable pleural effusion and consolidation. The current plan includes ongoing dialysis and clinical surveillance, as the patient remains under hospital care for his chronic renal failure and secondary complications.