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CASE OF 70 YEAR OLD MALE AKI on CKD

Greetings to one and all who are currently reading my blog.  This is Jasmisri,fifth semester medical student

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.

 CASE:-

A 70 year old male carpenter by occupation from miriyalagudem 

CHIEF COMPLAINTS

Fever since 2 days 

Burning micturition,hematuria,decreased urine output since 1  day

Blood vomiting since 1 day

SOB since 1 day

Pain in abdomen since 1 day

HISTORY OF PRESENTING ILLNESS

Patient was asymptomatic since 10 years

He is suffering from Asthma since 10 years

2 days ago first he developed fever  

He is not taking food properly  since 2 days(taking juices, milk not willing to eat)

Burning micturition with hematuria ,decreased utine output since 1 day( starting of micturition he had flow of blood followed by drops.His wife told that she can see drops of blood on his clothes while washing)

Hematemasis, he is retching since 1 day 4 episodes (force full vomiting leading to tear of oesophagus leading to Patches of blood vomiting) no food coming out.On thursday night 2 times,on friday morning 1time and night 1 time.

Due to penis clog unable to micturate ?

SOB since 1 day

Thursday he went to near by hospital they tried to put foleys catheter but unable to insert it so they came to our hospital.


PAST HISTORY

Last year he suffered with jaundice and decreased RBC(??) for 15 days  and episodes of burning micturition  and penis clog and body burning  subsided on taking medication 

No significiant history of DM,TB,Epilepsy,HTN

PERSONAL HISTORY

Diet:Mixed,decreased apetite since 2 days

Sleep: decreased sleep,before he used to sleep 9pm to 7am

Burning micturiton,hematuria

Constipation

No addictions

FAMILY HISTORY 

No significant family history

TREATMENT HISTORY

For Asthma- ROTACAP BECLOMETHASON





2 days back 





GENERAL EXAMINATION

  •  PALLOR
  • ICTERUS- mild
  • NO CYANOSIS
  • NO CLUBBING
  • NO KOILONYCHIA 
  • NO LYMPHADEONAPTHY
  • No Pedal edema






Vitals:-
  • Temp- afebrile
  • PR:85BPM.
  • RR: 16CPM.
  • Bp:120/80mm Hg
  • Spo2 : 100%
  • GRBS: 64 MG%.






SYSTEMIC EXAMINATION:-

A. Cardiovascular system 
  • S1 S2 HEARD
  • NO MURMURS.
B. Respiratory system 
  • NVBS heard
  • BAE +
  • TRACHEA CENTRAL.
C. Per abdominal examination 
  • SOFT
  • Scaphoid
  • Mild tenderness on left hypochondrium
D. Central nervous system:-
  • Conscious 
  • Speech normal
  • Cranial nerve-NAD
  • Motor system-NAD
  • Sensory system-NAD
  • Cerebellar system-NAD
  • No signs of meningial irritation/ meningitis

REFLEXES:-

                        RT. LFT
BICEPS-.        ++. ++
TRICEPS-.      ++. ++
SUPINATOR-.      ++ ++
ANKLE. -.            ++. ++
KNEE-.                ++ ++

INVESTIGATIONS:-


















Provisional Diagnosis:

Pyrexia under evaluation with thrombocytopenia
 AKI on CKD

Treatment:

Oral fluids 1.5 liter
Tab. Pan 40 mg PO/OD
Input/ output charting
Inj. Lasix 40mg IV BD
IVF 1 NS




Ent refferal






13/09/22


USG 

Treatment:-

Tab PAN 40mg PO OD
INJ Lasix 40mg BD IV
IVF @UO+ 30ML/HR
TAB DOLO 650mg SOS
Tab nodosis 550mg PO BD
Syrup cremaffin 15ml PO TID








  


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