A 60 year old male patient with ? UTI,CHRONIC CYSTITIS,? AKI ON CKD,Hypokalemia secondary to ? insulin use.

-

   A 60 year old male patient came to casualty with c/o high grade fever since 5 days,

Dry cough since 6 days,
SOB on exertion since 4 days.
C/o constipation since 4 days.
C/o burning micturation since 10 days.
No c/o decreased urine output.


HOPI: Patient was apparently asymptomatic 10 days back, then he had burning micturation,and high grade fever a/w nausea and dry cough, not a/w chills and rigor,he had constipation since 5 days.
 
PAST HISTORY: Patient is a k/c/o DM since 30 yrsand was on medication DAPAGLIFLOZIN 10 MG OD and TAB. VOGLIBOSE 0.3 MG OD and  on insulin since 2 days MIXTARD as his Sr.Creatinine is 2 mg/dl
K/C/O HTN since 30 years on TAB. AMLONG 2.5 MG OD .


PERSONAL HISTORY

DIET- MIXED
APPETITE- Normal
SLEEP- Adequate
B&B- Decreased
ADDICTIONS- Consumes alcohol occasionally.

GENERAL EXAMINATION:
patient is concious/coherent/cooperative, moderately built and nourished.

No pallor
No icterus
No clubbing
No edema
No lymphadenopathy.

Vitals: Temp- 101 F
            PR- 80 BPM
            RR- 19 CPM
            BP- 120/70 mm Hg
            SpO2- 98%@ RA
            GRBS- 387 mg/dl

Systemic examination:
CVS: S1 S2 + ,NO MURMURS
RS: BAE+, NVBS
CNS: INTACT
P/A: SOFT, DISTENDED, GUARDING + ,BS SLUGGISH.

INVESTIGATIONS























PLAN OF TREATMENT :
KCl one ampoule in 10 ml NS over 4 hrs.
Inj.MONOCEF 1gm IV BD
Inj PANTOP 40 mg IV OD
Inj.ZOFER 4 mg IV SOS
Inj.NEOMOL 1 gm IV SOS
Tab.DOLO 650 mg PO TID
Tab.AMLONG 2.5 mg PO OD
Inj.HUMAN ACTRAPID SC Acc to GRBS
Syp.LACTULOSE 10 ml PO BD
Syp.GRILLINCTUS 10 ml PO BD 


                                   DAY 1:

S- 


O- Temp- 101 F
            PR- 80 BPM
            RR- 19 CPM
            BP- 120/70 mm Hg
            SpO2- 98%@ RA
            GRBS- 387 mg/dl

A- UTI?
   CHRONIC CYTITIS
    GRADE 2 BPH 
    ?AKI ON CKD [DIABETIC NEPHROPATHY]

P-1] KCl one ampoule in 10 ml NS over 4 hrs.
2]Inj.MONOCEF 1gm IV BD
3]Inj PANTOP 40 mg IV OD
4]Inj.ZOFER 4 mg IV SOS
5]Inj.NEOMOL 1 gm IV SOS
6]Tab.DOLO 650 mg PO TID
7]Tab.AMLONG 2.5 mg PO OD
8]Inj.HUMAN ACTRAPID SC Acc to GRBS
9]Syp.LACTULOSE 10 ml PO BD
10] Syp.GRILLINCTUS 10 ml PO BD 



                                 DAY 2 :

S- 



O-Temp- 101 F
            PR- 86 BPM
            RR- 19 CPM
            BP- 110/70 mm Hg
            SpO2- 98%@ RA
            GRBS- 387 mg/dl 

A- ?UTI 
    CHRONIC CYSTITIS
    ?AKI ON CKD 
     DM + 
     HTN +  

P- 
1]IVF NS RL @ URINE OUTPUT + 30 ML/HR
2]Inj.MONOCEF 1gm IV BD
3]Inj PANTOP 40 mg IV OD
4]Inj.ZOFER 4 mg IV SOS
5]Inj.NEOMOL 1 gm IV SOS
6]Tab.DOLO 650 mg PO TID
7]Tab.AMLONG 2.5 mg PO OD
8]Inj.HUMAN ACTRAPID SC Acc to GRBS
9]Syp.LACTULOSE 10 ml PO BD
10] Syp.GRILLINCTUS 10 ml PO BD 


                              DAY 3 :

S- 

O-Temp- 101 F
            PR- 96 BPM
            RR- 19 CPM
            BP- 90/60 mm Hg
            SpO2- 98%@ RA
            GRBS- 387 mg/dl 

A- ?UTI 
    CHRONIC CYSTITIS
    ?AKI ON CKD 
     DM + 
     HTN +  


P- 
1]IVF NS RL @ URINE OUTPUT + 30 ML/HR
2]Inj.MONOCEF 1gm IV BD
3]Inj PANTOP 40 mg IV OD
4]Inj.ZOFER 4 mg IV SOS
5]Inj.NEOMOL 1 gm IV SOS
6]Tab.DOLO 650 mg PO TID
7]Tab.AMLONG 2.5 mg PO OD
8]Inj.HUMAN ACTRAPID SC Acc to GRBS
9]Syp.LACTULOSE 10 ml PO BD
10] Syp.GRILLINCTUS 10 ml PO BD 


            DAY 4 :

S- 

O-Temp- 101 F
            PR- 90 BPM
            RR- 19 CPM
            BP- 100/70 mm Hg
            SpO2- 98%@ RA
            GRBS- 387 mg/dl 

A- ?UTI 
    CHRONIC CYSTITIS
    ?AKI ON CKD 
     DM + 
     HTN +  


P- 
1]IVF NS RL @ URINE OUTPUT + 30 ML/HR
2]Inj.MONOCEF 1gm IV BD
3]Inj PANTOP 40 mg IV OD
4]Inj.ZOFER 4 mg IV SOS
5]Inj.NEOMOL 1 gm IV SOS
6]Tab.DOLO 650 mg PO TID
7]Tab.AMLONG 2.5 mg PO OD
8]Inj.HUMAN ACTRAPID SC Acc to GRBS
9]Syp.LACTULOSE 10 ml PO BD
10] Syp.GRILLINCTUS 10 ml PO BD 
11]TAB . NODOSIS PO/TID 
12]CAP BIO D3  PO/OD 
13]INJ LASIX 40 MG  IV/BD


             DAY 5 :







S- NO FEVER SPIKES , BURNING MICTURATION + , COUGH +


O-Temp- 101 F
            PR- 90 BPM
            RR- 19 CPM
            BP- 120/70 mm Hg
            SpO2- 98%@ RA
            GRBS- 387 mg/dl 

A- ?UTI 
    CHRONIC CYSTITIS
    ?AKI ON CKD 
     DM + 
     HTN +  

1]IVF NS RL @ URINE OUTPUT + 30 ML/HR
2]Inj.MONOCEF 1gm IV BD
3]Inj PANTOP 40 mg IV OD
4]Inj.ZOFER 4 mg IV SOS
5]Inj.NEOMOL 1 gm IV SOS
6]Tab.DOLO 650 mg PO TID
7]Tab.AMLONG 2.5 mg PO OD
8]Inj.HUMAN ACTRAPID SC Acc to GRBS
9]Syp.LACTULOSE 10 ml PO BD
10] Syp.GRILLINCTUS 10 ml PO BD 
11]TAB . NODOSIS PO/TID 
12]CAP BIO D3  PO/OD 
13]INJ LASIX 40 MG  IV/BD





Comments

Post a Comment

Popular posts from this blog

RIGHT HEART FAILURE SECONDARY TO COPD

-
Image
  under the guidance of Dr. Rishik (Intern) This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission. I have 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 SCENARIO: A 52yr old patient came to the ward on 29 June 2021 with chief complaints of  right lower limb swelling, intermittent fever (alive and well), shortness of breath  since 3days, and  burning micturition  for 15 days. HISTORY OF PRESENTING ILLNESS The patient was asymptomatic 5days ago, after which he developed right lower limb swelling up to the knee. No H/O trauma, thorn prick, nausea, vomiting c/o a small wound, watery discharge since 2 days Fever- 5days intermittent, low grade, a/w chill A light rise in temp sob on exertion -5days a/w cough- 1
Read more

30f with osteomalacia??

-
Image
A 30yr Old Female with ? Osteomalacia 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 is welcome 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 A 30yr old female, Daily wage Labourer by occupation came to OPD with cheif complaints of Pain in B/L Lower limbs since 2 years.  Patient wa
Read more

OSCE QUESTIONS

-
1) Having history of BPH and DM 2,if he develops renal failure what will be the cause. Pre renal or post renal?  2)How to divide the insulin dosage?  3) How adipokines causes insulin deficiency?  4) How furosemide causes tetany and muscle cramps ?  5) How to furosemide causes weakness ?  6) In case of liver cirrhosis and heart failure , how to differentiate the edema is caused due to liver failure or heart failure ?  7) How do anemia cause hypopitutarism?  8) Why in IVC obstruction there are dilated veins ?? And why their fillings occurs from bottom to top ?  9) What are the causes of vertebro basillar insufficiency?  10) What is the efficacy of vertin ?  11) What is the effectiveness of promethazine / ondencetron / vertin in cases of relieveing vestibular vertigo ?
Read more