Case history

 December 21,2021

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 comment box is welcome .

Date of administration:18-12-2021

A 60 year old male patient came to the opd with chief complaints of fever since 5 days , constipation & short ness of breathe since 4 days, burning micturation since 10 days, cough since 6 days. 

History of present illness :

Patient was apparently asymptomatic 10 days back then he complaint of high grade fever associated with nausea , no rigor & chills, dry cough, decreased urine out put with burning micturation ,constipation , short ness of breathe

He went to local doctor & was diagnosed as kidney injury

Past history:

Known case of diabetes & hypertension since 30 years

Not a know case of  asthma, epilepsy, TB 

Personal history:

Dite : mixed

Appetite : normal

Sleep : adequate 

Bowel & bladder movements : decreased

Occasionally alcoholic

Family history:

No similar complaints in the family

General physical examination:

Patient is conscious, coherent, co-operative

He is well oriented to time place and person

He is  moderately build & nourished 

No icterus, cyanosis, clubbing, generalized lymphadenopathy , pedal edema 









Vitals :

Temperature:101F

BP :120/70mmHg

PR:80bpm

Respiration rate: 19cpm

Systemic examination :

Cardiovascular system :

S1 and S2 heard 

No murmurs

Respiratory system :

Normal vesicular breath sounds are heard 

Position of trachea : central 

BAE +

Per abdomen :

Soft & distended

Guarding positive 


CNS :

No abnormality directed 

Investigations























 



Provisional diagnosis :  urinary tract infection
                                            Chronic cystitis 
                                             AKI on CKD 
         Hypokalemia secondary to insulin                                                                                              

Treatment:

KCl 1 ampoule in 10 ml NS over 4 hrs. 

Inj. PANTOP 40 mg IV OD

Inj. MONOCEF 1 gm IV BD 

Inj. ZOFER 4 mg IV SOS

Inj. NEOMOL 1gm 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 







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