A 24 yr old male came to casuality with reduced urine output.
March 13, 2022
This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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.
A 24 year old male patient, resident of Devarakonda, Cowherd by occupation came to our hospital with chief complaints of-
1. Reduced urine output with involuntary in action
2. Shortness of breath which is insidious in onset, gradually progressive
3. Pedal edema.
Date of admission :- 09/03/2022
History of present illness:-
Patient was apparently asymptomatic 10 days back and developed fever which is insidious and intermittent, and reduced urine output with involuntary in action.
History of past illness:-
Not a known case of diabetes, hypertension, tb, epilepsy
10 years ago he had same problem.
Personal history:-
Patient has normal eating habit with mixed diet.
No alchohol consumption and no smoking.
Daily routine:-
Patient used to wake up at 7.00AM , takes breakfast at 9.00AM .Then he goes to his work and takes rice in between 4.00PM-5.00PM and dinner at 8.00PM and goes to bed by 9.00PM.
Family history:-
No significant family history.
General examination:-
Patient is conscious, coherent, cooperative and well oriented to time, place and person.
Pallor present
No icterus
No clubbing
No lymphadenopathy
Pedal edema present
Vitals:-
Temperature-99 F
Pulse rate- 88 bpm
RR-22 /min
BP-180/100 mmhg
SPO2-97% at room air
RBS-122 mg/dl
Investigations:-
CUE
Hemogram
RFT
LFT
ABG
Serum electrolytes
Serum creatinine
Blood urea
Chest X-ray
ECG
Non-contrast computerized tomography (NCCT)
X-ray right foot
X-ray left hand
Ultra sound scan of abdomen
Provisional diagnosis:-
AKI on CKD
Abscess of right dorsum of foot
Neurogenic bladder
Bladder outflow obstruction
Urinary tract tb
Severe hydronephrosis with thinned out renal parenchyma
Thickened urinary bladder wall
Peripheral lung consolidation with relative central lucency in right lung middle and lower lobe
Peripheral consolidation in left lower lobe
Fungal infection
Covid-19 pneumonia
Septic emboli
Treatment-
Inj. Piptaz 2.25mg × IV × QID
Inj. Clindamycin 300mg × IV × TID
Inj. Pantop 40mg × IV × SOS
Inj. Lasix 40mg × IV × BD
Tab. Nodosis 500mg × PO × BD
Tab. Shelcal 500mg × PO × OD
Tab. Fluconazole 150mg × PO × BD
Cap. BIO-D3 0.25mg × PO × OD
Syp. Potchlor 10ml × PO × TID
Comments
Post a Comment