FINAL PRACTICAL SHORT CASE

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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box

07-06-2022

Hall ticket no. 1701006048

CHIEF COMPLAINTS:

80 years old male , agriculture labourer by occupation came to OPD with the chief complaints of

•FEVER - since 7 days

•Decreased urine output associated with burning micturition since 6 days.

History of presenting illness

Patient is apparently asymptomatic 7 days back, Then he developed fever which is  insidious in onset, intermittent  with no diurnal variations which   relieved on taking medication.

✓  Associated with chills, rigors and generalised body pains. 

✓  Associated with an episode of vomiting 2 days back.conent of vomitus is food,  which is non bilious, not foul smelling.

✓ No History of cough, cold, shortness of breathe, night sweats.

✓There is burning micturition which is experienced at the start of the urinary flow and relieved after the urination and decreased urine output since 2 days which is not associated with any hematuria.

Past history

H/o similar complaints in the past.

History of patient


24 years ago:-
Nephrectomy left side-donated to his brother.


24 years ago:-
Diagnosed with hypertension..

10years ago:-
Complaint of fever+decreased urine output+burning micturition..
Given antibiotics+diuretics..
Diagnosed with renal problem..
One session of dialysis


Recurrent episodes of fever+burning micturition
  Consulted to local RMP
Used antibiotics for 2years..


7days ago:- fever
6days ago:-
Vomiting +decreased urine output+burning micturition.

He is known case of HYPERTENSION since 24years. Not a known case of diabetes, tuberculosis,asthma and epilepsy.

 PAST Surgical history

He underwent a nephrectomy surgery 24yrs ago donated to his brother.

Personal history

Appetite - normal

Diet- mixed

Sleep - adequate

Bowel - constipation is present

Bladder - oliguria since 6 days, associated with burning micturition.

Allergies- none

Addiction- 3 beedi/ day from 27yrs of age

Alcohol- occasionally 

Stopped both alcohol and smoking after the nephrectomy surgery.

General examination

Patient is conscious, coherent, co operative and well oriented to time, place, and person moderately build and nourished.

  Thereis  pallor and pedal edema , but no icterus , cyanosis,clubbing, lymphadenopathy.

Vitals: Febrile 99.2F

BP- 150/90 mmHg ( on medication)

Respiratory rate- 18 cpm

Pulse rate - 76 bpm

Systemic examination:

Abdomen examination:

Inspection: 




Umbilicus inverted , No abdominal distention,no  visible pulsations,scars and swelling.

PALPATION:

      Soft, non tender, no organo megaly.

  AUSCULTATION:

BOWEL SOUNDS HEARD

Cardio vascular examination:

    No visible pulsations, scars, engorged veins. No rise in jvp 

   Apex beat is felt at 5 Intercoastal space medial to mid clavicular line.

    S1 S2 heard . No murmurs.

Respiratory system

    Shape of chest is elliptical, b/l symmetrical.

    Trachea is central. Expansion of chest is symmetrical

      Bilateral Airway Entry - positive

      Normal vesicular breath sounds

CNS EXAMINATION: 

No signs of meningeal signs

Cranial nerves: normal

Sensory system: normal

Motor system: normal

Reflexes: Right.     Left. 

Biceps.      ++.          ++

Triceps.    ++.          ++

Supinator ++.         ++

Knee.         ++.         ++

Ankle        ++.         ++

Gait: normal.

INVESTIGATIONS:









Acute (secondary urosepsis) on chronic kidney disease might be due to recurrent urinary track infection.

Treatment:

Inj. Piptaz -2.25gm/tid

Tab. Lasix -40ug/po/ bd

Tab. Zofer -4mg/po/ sos

Tab. Dolo -650/ po/ sos

Tab. Pan 40mg /po/ od

Nebi. Duolin and Budecort 6hrly

Syr. Mucaine gel 15ml/po/ bd before meal 15min

Syrup. Cremaffin 15ml/po/ sos.









Comments

Popular posts from this blog

INTERN ONLINE ASSESSMENT

60 YEAR OLD FEMALE WITH HISTORY OF FEVER AND SHORTNESS OF BREATH.

MEDICINE BLENDED ASSIGNMENT (MAY)