58year old man with decreased urinary stream since 3days and anuria and pain abdomen for 1day
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 the comment box are welcome.
Here is a case i have seen:
A 58yr old male came with complaints of
Decreased urinary stream since 3days
not passing urine since 1 day
Pain abdomen since 1day.
History of presenting illness:
Patient was apparently asymptomatic 4days back then developed cough which was not associated with sputum followed by fever which was low grade,continuous,not associated with chills then developed dribbling of urine and decreased urinary output since 3 days associated with burning micturition.No hesitancy or urgency.
Past history:
K/c/o of Diabetes since 5yrs (metformin 500mg + glimiperide 1mg)
HTN since 8months (Tab.Amlong 5mg + Atenolol 50mg)
Cataract surgery left side and spine surgery 3yrs back.
Not a k/c/o asthma,elilepsy,ckd,cva.
Occasional alcoholic (2peeps whiskeys)
Not a known smoker
Vitals:
Bp:100/60
PR:76bpm regular in rythm and normal in volume
Temp:Afebrile
RR: 20/min
General Examination:
Patient was conscious,coherent,cooperative,moderately built n moderately nourished.
No pallor,icterus,cyanosis,clubbing,kilonychia,lymphadenopathy.
There is a grade 2 edema,non pitting,nontender.
Systemic examination:
CVS:S1,S2 heard.No murmurs
CNS:Intact
RS:NVBS heard,BAE +
P/A: soft,nontender .
Investigations:
Prerenal AKI with k/c/o of DM-2 and HTN
Treatment:
Inj.Piptaz 2.5mg/IV/TID
Inj.Pantop 40mgIV OD
Inj.Lasix 40mg IV BD
Inj.HAI S/C according to sliding scale
Tab.Amlong 5mg OD
Strict I/O charting
GRBS charting 6th hrly
Bp charting 2nd hrly
Temp & pulse rate charting 4th hrly
Comments
Post a Comment