General Medicine

Date-19/12/21.

"This is an online E log book to discuss our patients 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 clinical problems with collective current best evidence based inputs".

Date of admission-13/12/21.

70 years old male daily wage labourer by occupation came to the casuality with the chief complaints of;

 BURNING MICTURATION -since 4 days

SHORTNESS OF BREATH with wheeze-since 4 days

FEVER WITH CHILLS-since 4 days

HISTORY OF PRESENT ILLNESS;

Patient was apparantly asymptomatic 4 days  ago having a normal daily routine,he used to wakeup early in the morning around 5.00am and around 9 am he used to go to farm land, he used to return home by 6.pm and he used to sleep by 9.pm.4 days ago he developed fever with chills,then their family members took him to local hospital and they subscribed some medications,his fever didn't subsided,

then he also developed BURNING MICTURITION,SOB  associated with wheeze.so,immediately he was brought to Kims where he was diagnosed with AKI.

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 .

NO HTN,DM,ASTHMA

PERSONAL HISTORY 

Marital status - married 

Occupation - daily wage labourer 

Appetite - Normal 

Diet - Mixed 

Bowel and bladder movements - regular

Addictions - 

Chronic alcoholic since 20 years daily 180 ml.

Chronic smoker since 20 years  daily 2-4 beedis per day.

FAMILY HISTORY;

No significant family history .

GENERAL EXAMINATION :

Patient is conscious , coherent, cooperative 

Pallor positive 

No icterus , cyanosis , lymphadenopathy, edema .

Systemic examination 

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 findings 

INVESTIGATIONS 

DIAGNOSIS;

AKI 2° TO UTI WITH PAST H/O COVID, PULMONARY TB

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