60Y OLD MALE WITH UTI WITH AKI ON CKD WITH LEFT LOWERLIMB CELLULITIS
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
60/M CAME TO CASULATY WITH CHIEF COMPLAINTS OF
•FEVER SINCE 10 DAYS
•BURNING MICTURITION SINCE 10 DAYS
•PEDAL EDEMA IN LOWERLIMBS (left>right) SINCE 7 DAYS
•SOB GRADE (2-3) SINCE 2 DAYS.
HISTORY OF PRESENTING ILLNESS:-
Patient was apparently asymptomatic 10 days when he developed FEVER which was insidious in onset, high grade, intermittent , relieves on taking medication, associated with chills and rigor amd burning micturition.
Patient complains of PEDAL EDEMAwhich is bilateral (left>right) extending upto knees.
Patient developed blebs over left foot since 3 days. Watery discharge is observed to be oozing out of the blebs since 2 days.
Patient also complains of SHORTNESS OF BREATH (grade 2-3) since 2 days which is insidious in onset and non progressive.
No h/o orthopnea or PND.
•FEVER SINCE 10 DAYS
•BURNING MICTURITION SINCE 10 DAYS
•PEDAL EDEMA IN LOWERLIMBS (left>right) SINCE 7 DAYS
•SOB GRADE (2-3) SINCE 2 DAYS.
HISTORY OF PRESENTING ILLNESS:-
Patient was apparently asymptomatic 10 days when he developed FEVER which was insidious in onset, high grade, intermittent , relieves on taking medication, associated with chills and rigor amd burning micturition.
Patient complains of PEDAL EDEMAwhich is bilateral (left>right) extending upto knees.
Patient developed blebs over left foot since 3 days. Watery discharge is observed to be oozing out of the blebs since 2 days.
Patient also complains of SHORTNESS OF BREATH (grade 2-3) since 2 days which is insidious in onset and non progressive.
No h/o orthopnea or PND.
PAST HISTORY:-
Patient is a k/c/o HTN since 10 years and is on medication Telma-H
Patient gives h/o fall from tree 10 yrs ago after which he had low back ache and neck pain . He toom some unknown pain killers for the pains for a period of 6 yrs. After which he went ro some hospital where they performed Sx to ?cervical spine.
PERSONAL HISTORY:-
Diet is mixed.
Appetite is normal.
Sleep is adequate.
Bowel and bladder movements are regular.
Addictions- chronic smoker since 10 yrs , smokes beedi 1 pack per day but reduced to 3 or 4 beedis per day since few months.
PERSONAL HISTORY:-
Diet is mixed.
Appetite is normal.
Sleep is adequate.
Bowel and bladder movements are regular.
Addictions- chronic smoker since 10 yrs , smokes beedi 1 pack per day but reduced to 3 or 4 beedis per day since few months.
Consumes alcohol intermittently since 10 years. Stopped 4 yrs back
ON EXAMINATION:-
Patient is conscious, coherent and cooperative.
No signs of pallor, icteurs, cyanosis, Lymphadenopathy . Edema is present-B/L lowerlimb (L>R) pitting type extending upto
ON EXAMINATION:-
Patient is conscious, coherent and cooperative.
No signs of pallor, icteurs, cyanosis, Lymphadenopathy . Edema is present-B/L lowerlimb (L>R) pitting type extending upto
knees.
Vitals:-
PR=84bpm
BP=150/80mmhg
RR=24cpm
GRBS=136mg/dl
TEMPERATURE =98.6F
SPO2=98%@RA
CVS- S1,S2 +, no murmurs
RS- BAE+, NVBS
P/A- Soft, NT
PR=84bpm
BP=150/80mmhg
RR=24cpm
GRBS=136mg/dl
TEMPERATURE =98.6F
SPO2=98%@RA
CVS- S1,S2 +, no murmurs
RS- BAE+, NVBS
P/A- Soft, NT
CNS- Cranial nerves- normal
Sensory System - Normal
Weakness in right upper limb and lower limb
Motor System -
• Power - Decreased in RIGHT UL (3/5) and LL (4/5)
• Tone –Normal in all 4 limbs.
• Reflexes
RT. LT.
B + +
T + +
S + +
K + +
A + +
Plantar Extensor Mute
INVESTIGATIONS:-
23.7.2021
GLYCATED HEMOGLOBIN =6.5%
SERUM CREATININE =4.8mg/dl
BLOOD UREA= 163mg/dl
24HR URINARY PROTEINS =1578mg/day
24HR URINARY VOLUME=2000ml.
CBP
Hb=10.3%
TC=11,600 cells/mm3
Neutrophils=80%
Lymphocytes=10%
Eosinophils=3%
Monocytes=7%
Platelet=4.02 lakhs/mm3
PROVISIONAL DIAGNOSIS:-
UTI with AKI on CKD with LEFT LOWERLIMB CELLULITIS.
DAILY UPDATES:-
Date:- 21/7/2021
1) Inj. Monocef 1g IV/BD
2) Inj. Metrogyl 500mg IV/TID
3) Inj. Pan 40mg IV/OD
4) Inj. Lasix 40mg IV/BD
5) Tab. Met XL 50mg PO/OD
6) Inj. Clexane 40mg S/C OD
7) Tab. Nodosis 500mg PO/BD
8) Tab. Orofer XT 100mg PO/BD
9) Left Lowerlimb MgSO4 dressing
10) B/L lowerlimb elevation
11) Crepe bandage application.
12) Tab. PCM 650mg PO/TID
13) Syp. Citralka 15ml/PO/BD
14) Inj. Tramadol 1 amp in 100ml NS IV/OD
15) Fever charting.
16) I/O charting.
Date:- 22/7/2021
1) Inj. Monocef 1g IV/BD
2) Inj. Metrogyl 500mg IV/TID
3) Inj. Pan 40mg IV/OD
4) Inj. Lasix 40mg IV/BD
5) Tab. Met XL 50mg PO/OD
6) Tab. Nodosis 500mg PO/BD
7) Tab. Orofer XT 100mg PO/BD
8) Inj. Tramadol 1 amp in 100ml NS IV/OD
9) Syp. Citralka 15ml/PO/BD
10) B/L lowerlimb elevation and Left Lowerlimb MgSO4 dressing.
11) I/O charting
12) Tab. Cilnidipine 10mg PO/OD.
Date:- 23/7/2021
1) Inj. Monocef 1g IV/BD
2) Inj. Metrogyl 500mg IV/TID
3) Inj. Pan 40mg IV/OD
4) Inj. Lasix 40mg IV/BD
5) Tab. Met XL 50mg PO/OD
6) Tab. Nodosis 500mg PO/BD
7) Tab. Orofer XT 100mg PO/BD
8) Inj. Tramadol 1 amp in 100ml NS IV/OD
9) Syp. Citralka 15ml/PO/BD
10) B/L lowerlimb elevation and Left Lowerlimb MgSO4 dressing.
11) I/O charting
12) Tab. Cilnidipine 10mg PO/OD.
13) Inj. Erythropoietin 4000 IU s/c thrice weekly
14) Inj. Optineuron 1 amp in 100ml NS IV/OD
15) Tab. Shelcal - CT PO/OD
16) Tab. Jointen PO/OD
Comments
Post a Comment