AMC Unit 1

 This is 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 based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.


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


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