GENERAL MEDICINE CASE

 December 21 , 2021 

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence base inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

A 70 year old patient came to OPD with chief complaints of 

Burning micturition since 10 days  

Shortness of breath since 10 days 

Fever and chills since 10 days

History of present illness :

Patient was apparently asymptomatic 2 weeks back then he developed weakness for which he visited a hospital in nalgonda where the tests were done andbdiagnosed with kidney disease. Then he started using medication and due to which he developed fever and chills then he visited KIMS. 

The normal routine of the patient 2 weeks ago was he used to wakeup 5'0 clock in the morning and do all the household work and then used to go for farming around 10 and then used to return home in the evening. 2 weeks back after the work he experienced weakness , pedal edema , burning micturition and stopped the work.

Past History : 

The patient is not a known case of Diabetes

mellitus , Hypertension and asthma. 

Known case of Tuberculosis 20 years back used

HAZE regimen for 6 months.

Family history : 

No relevant family history 

Medical history : 

Not allergic to any known drugs 

Personal history :

Diet - Mixed 

Appetite - Reduced 

Sleeping - Adequate 

Bowel and bladder movement - Regular 

Habits - chronic alcoholic since 20 years daily

180mL 

Chronic smoker since 20 years 2-4 beedis per day 

General examination : 

Patient is conscious , coherent and cooperative 

Well Oriented to time , place and person 

Pallor is present 

No icterus 

No cyanosis 

No clubbing 

No edema 

Pulse rate -69 / min

Blood pressure - 130 / 80 mmHg 

Respiratory Rate - 16 cpm

SpO2 - 98% at room air

GRBS - 105 mg / dl 

Systemic examination : 

CVS : 

S1 S2 heard 

No thrills 

No murmurs heard 

RESPIRATORY SYSTEM :

No dyspnea 

Wheezing is present 

Trachea is in central position 

Vesicular breath sounds heard 

ABDOMEN : 

Scaphoid in shape 

No tenderness 

No palpable mass 

Normal hernial orifice 

No free fluid 

No bruits 

Liver is not palpable 

CNS : 

Patient is conscious 

Speech is present 

Reflexes are normal

PROVISIONAL DIAGNOSIS

 AkI ?

INVESTIGATION

Treatment :

1.INJ.LASIX 20 MG IV/BD 

2.INJ PIPTAZ 4.5 GM IV/STAT 

3.INJ.PANTOP 40 MG IV/SDS 

4.INJ ZOFER 4 MG IV/STAT 

5.NEB.BUDECORT 12 HRLY 

DUOLIN 6 HRLY 

6.STICT I/O CHARTING 

7.BP,TEMPERATURE MONITORING 4 HRLY