AMC Unit 1
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Sunday,December 19th
A 70year old male came with Fever,SOB,Burning micturition.
B.Sushma ,9th semester
Roll no.154
December 19th,2021
A CASE DISCUSSION ON Fever,SOB,Burning micturition.
I've 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 a diagnosis and treatment plan.
CASE PRESENTATION:
A 70yr old male, daily wage labourer by occupation presented to our opd on 13th december 2021 with
CHEIF COMPLAINTS of
C/O BURNING MICTURITION
C/O SOB
C/O fever with chills
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1week ago then he developed BURNING MICTURITION,SOB associated with wheeze ,
H/O FEVER(on and off ) with chills
No h/o facial puffiness ,pedal edema
No H/O loin pain
PAST HISTORY
known case of TB 20 years back for which he took 6 month hrze regimen
and known case covid 4months back
NO HTN,DM,ASTHMA
PERSONAL HISTORY
Marital status - married
Occupation - daily wage labourer
Appetite - Normal
Diet - Mixed
Bowel and bladder movements - decreased
Addictions -
Chronic alcoholic since 20 years daily 180 ml.
Chronic smoker since 20 years daily 2-4 beedis per day.
No significant family history .
GENERAL EXAMINATION :
Patient is conscious , coherent, cooperative
Pallor positive
No icterus , cyanosis , lymphadenopathy, edema
VITALS
BP : 120/ 80MM HG
PR : 86/ MIN
RR : 16/ MIN
SPO2: 98% on RA
GRBS : 105 mg/dl
SYSTEMIC EXAMINATION
CVS : S1, S2 +
RS : BAE + , decreased breath sounds on b/l IAA,IMA
P/A : soft , nontender
CNS : No positive findings
Clinical pictures:
INVESTIGATIONS:
ECG on 14/12/2021(12:15AM)
ECG on 14/12/2021(12:50PM)
Chest x-ray
USG
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
15/12/21
S- 1 episode of fever spikes+
O-
TEMP-98.3F
GRBS- 116mg/dl
BP- 100/80mmhg
Pr- 70bpm
Spo2-99% on ra
Rr-21cpm
CVS- S1, S2 heard
CNS- NAD
RA- BAE+
P/A- soft
I/O- 3300/ 1950
A- AKI on CKD (CKD 2° to ?ANALGESIC NEPHROPATHY)
AKI 2° TO UTI WITH PAST H/O COVID, PULMONARY TB
P-
IVF- NS, RL UO+30ML/HI
INJ LASIX 20MG IV/BD (8AM-4PM-X, IF SBP>110MMHG)
INJ PANTOP 40MG IV/OD
INJ. PIPTAZ 2.25GM IV/TID
INJ. ZOFER 4MG IV/SOS
INJ. NEOMAL 1GM IV/SOS(IF TEMP≥101F)
T. PCM 500MG PO/TID
T. NODOSIS 500MG PO/BD
T. ULTRACET ½ PO/SOS
NEB WITH BUDECORT 12TH HRLY AND DUOLIN 6TH HRLY
I/O CHARTING
MONITOR VITALS
TEMP CHARTING
16/12/21
AMC
bed no. 8
70/M
S- 1 episode of fever spikes+
O-
TEMP-98.3F
GRBS- 116mg/dl
BP- 100/80mmhg
Pr- 70bpm
Spo2-99% on ra
Rr-21cpm
CVS- S1, S2 heard
CNS- NAD
RA- BAE+
P/A- soft
I/O- 3300/ 1950
A- AKI on CKD (CKD 2° to ?ANALGESIC NEPHROPATHY)
AKI 2° TO UTI WITH PAST H/O COVID, PULMONARY TB
P-
IVF- NS, RL UO+30ML/HI
INJ LASIX 20MG IV/BD (8AM-4PM-X, IF SBP>110MMHG)
INJ PANTOP 40MG IV/OD
INJ. PIPTAZ 2.25GM IV/TID
INJ. ZOFER 4MG IV/SOS
INJ. NEOMAL 1GM IV/SOS(IF TEMP≥101F)
T. PCM 500MG PO/TID
T. NODOSIS 500MG PO/BD
T. ULTRACET ½ PO/SOS
NEB WITH BUDECORT 12TH HRLY AND DUOLIN 6TH HRLY
I/O CHARTING
MONITOR VITALS
TEMP CHARTING
17/12/21
AMC
bed no. 8
70/M
S- 1 episode of fever spikes+
O-
TEMP-98.3F
GRBS- 116mg/dl
BP- 100/80mmhg
Pr- 70bpm
Spo2-99% on ra
Rr-21cpm
CVS- S1, S2 heard
CNS- NAD
RA- BAE+
P/A- soft
I/O- 3300/ 1950
A- AKI on CKD (CKD 2° to ?ANALGESIC NEPHROPATHY)
AKI 2° TO UTI WITH PAST H/O COVID, PULMONARY TB
P-
IVF- NS, RL UO+30ML/HI
INJ LASIX 20MG IV/BD (8AM-4PM-X, IF SBP>110MMHG)
INJ PANTOP 40MG IV/OD
INJ. PIPTAZ 2.25GM IV/TID
INJ. ZOFER 4MG IV/SOS
INJ. NEOMAL 1GM IV/SOS(IF TEMP≥101F)
T. PCM 500MG PO/TID
T. NODOSIS 500MG PO/BD
T. ULTRACET ½ PO/SOS
NEB WITH BUDECORT 12TH HRLY AND DUOLIN 6TH HRLY
I/O CHARTING
MONITOR VITALS
TEMP CHARTING
18/12/21
AMC
bed no. 8
70/M
S- 1 episode of fever spikes+
O-
TEMP-98.3F
GRBS- 116mg/dl
BP- 100/80mmhg
Pr- 70bpm
Spo2-99% on ra
Rr-21cpm
CVS- S1, S2 heard
CNS- NAD
RA- BAE+
P/A- soft
I/O- 3300/ 1950
A- AKI on CKD (CKD 2° to ?ANALGESIC NEPHROPATHY)
AKI 2° TO UTI WITH PAST H/O COVID, PULMONARY TB
P-
IVF- NS, RL UO+30ML/HI
INJ LASIX 20MG IV/BD (8AM-4PM-X, IF SBP>110MMHG)
INJ PANTOP 40MG IV/OD
INJ. PIPTAZ 2.25GM IV/TID
INJ. ZOFER 4MG IV/SOS
INJ. NEOMAL 1GM IV/SOS(IF TEMP≥101F)
T. PCM 500MG PO/TID
T. NODOSIS 500MG PO/BD
T. ULTRACET ½ PO/SOS
NEB WITH BUDECORT 12TH HRLY AND DUOLIN 6TH HRLY
I/O CHARTING
MONITOR VITALS
TEMP CHARTING
19/12/21
AMC
bed no. 8
70/M
S- Abdominal discomfort, Burning micturition +ve , no fever spikes since yesterday .
O-
TEMP-98.3F
BP- 100/60mmhg
Pr- 70bpm
Spo2-99% on RA
Rr-20cpm
CVS- S1, S2 heard
CNS- NAD
RA- BAE+
P/A- soft
I/O- 2950/2500
A- AKI on CKD (CKD 2° to ?ANALGESIC NEPHROPATHY)
AKI 2° TO UTI WITH PAST H/O COVID, PULMONARY TB
P-
IVF- NS, RL UO+30ML/HI
INJ LASIX 20MG IV/BD (8AM-4PM-X, IF SBP>110MMHG)
INJ PANTOP 40MG IV/OD
INJ. MEROPENEM 500MG /IV/OD
T. PCM 500MG PO/TID
T. NODOSIS 500MG PO/BD
T. ULTRACET ½ PO/SOS
T.OROFER-XT PO/BD
NEB WITH BUDECORT 12TH HRLY AND DUOLIN 6TH HRLY
SYP CITRALKA 15ML IN GLASS OF WATER PO/TID
I/O CHARTING
MONITOR VITALS
TEMP CHARTING
