gm 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.

Chief complaint:-
A 61 years old male presented with the chief complaints of 
-pain in the left loin
-decreased urine output
-Swelling in the legs
-Constipation and fever

History of presenting illness:-
Patient was apparantly asymptomatic 15days back.
Then he had 1 episode of vomiting followed by fever associated with chills and rigors.
Then he developed pain in the left loin associated with decreased urine output since 15days.
The next day he developed constipation.

History of past illness:-
K/c/o :-Diabetes mellitus since 3 years
K/c/o:- hypertension since 1 year.

Personal history:-
Diet:-mixed
Appetite:- normal
Bowel:- constipation 
Micturation:-decreased urine output
Addiction:- consumes alcohol since 30years 90ml/day and he is a non smoker.

No history of similar complaints in the family.

General examination:-
The patient is c/c and well oriented with time and place.

Vitals:-
Pulse rate:- 88bpm
Respiratory rate:- 22/min
Bp:- 130/80mmhg
Temperature:- Afebrile
GRBS:- 221mg/dl

Physical examination:-
Pallor:-absent
Icterus:-absent
Cyanosis:-absent
Clubbing:-absent
Generalized lymphadenopathy:-absent
Oedema:- oedema of feet is present

Systemic examination:-

Cvs
S1 s2 are heard with no murmers

Rs
BAE :- present
Vesicular breath sound are heard

Abdomen
Scaphoid shape
No tenderness
No palpable mass
No hernial orifice

Cns
Counciousness : drowsy
Speech : slurred

Investigations:-
On 26/08/2022
On 27/08/2022

Provisional diagnosis:

AKI with fever.


Plan of care:

Haemodialysis.


Treatment:

Inj.LASIX 40mg i.v b.d

Inj.NEOMOL 1gm i.v

Tab.DOLO 650 mg po/tid

Syp.CREMAFFIN 5 ml

Inj.PAN 40 MG I.V OD.

Tab.SHELCAL 500 mg po/od








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