GM case E - log

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A 65YR OLD MALE 


         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 patient’s clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online portfolio and your valuable inputs on the comment box.

Note: This is an ongoing case and will be uploaded as and when information is provided. This E-Log has been made under the guidance of Dr. Sri Ram sir.


CASE SCENARIO


A 65yr old male patient with chief complaints of 
  • Generalized weekness and not able to walk since 2 weeks
  • Fever, loss of appetite and nausea since 1 week
  • B/L Pedal edema since 1 week
  • Decreases urine output since 1 week
  • Burning micturition since 1 week
  • Drowsiness since 1 day

HISTORY OF PRESENT ILLNESS


       Patient was apparently alright 1 week back then he had 
  1. Insidious onset of fever, low grade, intermittent, not associated with chills and rigors. Relived on taking medication.
  2. Pedal edema - insidious in onset, gradually progressive from foot to knee and is pitting type.
  3. No PND and orthopnea
  4. Fever is associated with loss of appetite, nausea, generalised weakness and unable to walk
  5. There is decreased in the urine output and burning micturition since 1 week
  6. From 1day the patient is drowsy and excessively sleepy

PAST HISTORY


      Not a known case of diabetes, HTN, CAD, asthma and TB


PERSONAL HISTORY


Occupation -   used to work as labour in crop fields.
Appetite      -   Decreased
Diet              -   mixed
Bowel movements - regular 
Micturution -  decreased
Alcohol - Regular - takes 180ml/day since 3years

FAMILY HISTORY


       No significant family history


GENERAL EXAMINATION


No pallor 
No icterus 
No cyanosis and clubbing
No lymphadenopathy 
Edema - pedal and pitting type

Vitals


Temperature - 99.4°F
PR - 103bpm
RR - 28cpm
BP - 130/70mm Hg
SpO2 - 95%
GRBS - 86 mg%

SYSTEMIC EXAMINATION


CVS :

S1 and S2 heard 
No murmers 


Respiratory : 

NVDS heard
BAE + 
Trachea - central


CNS : 

Conscious
No signs of meningeal irritation

REFLEXES

                              RT                 LT
         Biceps          +                   +

         Triceps         +                   +

         Supinator     +                   +

         Knee             +                   +

          Ankle           +                   +
 
          Plantor     :  Flexor     
          


Per Abdomen : 

Soft
Non tender 
Non distended

PROVISIONAL DIAGNOSIS

       UTI with AKI with hyponatremia


INVESTIGATIONS 


1) ECG 






2) Ultrasound




3) Chest X - ray




4) ABG




5) RFT





6) Serology 



7) Haemogram





TREATMENT


• FOSFOMYCIN sachet - 3mg in 1glass of water/ stat

• Tab DOLO 650mg  PO/ TID

• Tab NODOSIS  PO/BD

• Strict I/O charting

• Condome Catheterization

• Inj LASIX 40mg IV/BD if SBP > or = 110mmHg

• IVF 20NS @75ml/hr

• Temperature charting 4th hourly

• GRBS charting 8th hourly

• BP / PR / RR / Spo2 charting 2nd hourly














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