70 year male with fever

This is an online E logbook 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 a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with collective current best evidence-based inputs.



PRESENTING COMPLAINTS: 
C/O Dribbling of urine since 10 days.
C/O Fever since 7 days.
C/O Myalgia since 5 days.
C/O Dry cough since 2 days.

HOPI:
A 70 year male, labourer by occupation presented to the casuality with complaints of dribbling of urine since 10 days. No history of dysuria/ burning micturition/ hematuria. History of high grade Intermittent fever associated with chills releived on taking medication since 7 days. History of myalgia since 5 days and history of dry cough since 2 days.

PAST ILLNESS:
The patient had complaints of severe low back pain, paresthesia in the lower limbs and sough for consultation and underwent L-S spine fixation under GA in 2004, which was uneventful.
He was diagnosed with Diabetes Mellitus on regular health checkup which were conducted in the Health center; and started on Oral hypoglycemic agents since 2010.
History of loin pain radiating to the groin on the right side in the year 2017; Patient soughted for consultation for the same and treated conservatively.

PERSONAL HISTORY:
He was moderately built and nourished.
Non vegetarian.
Sleep was adequate.
Appetite decreased.
Bowel and bladder are irregular.
Smoker: started at the age of 24 years and discontinued in the year 2004; he used to smoke 2 beedi's daily during initial years which progressed to 10 beedi's daily. 
Occasional Alcoholic : started at the age of 26 years; 90ml/day; last binge was 12 days ago(90ml).

GENERAL EXAMINATION:
Patient was conscious and coherent.
Febrile, Temp : 102°F.
PR: 102 bpm; RR: 19 cpm; BP: 110/80mmHg; GRBS: 247 mg/dl.
CVS: S1, S2+; R/S: BAE+, Clear; P/A: Soft, Non tender, BS+, Hypogastric fullness+; CNS: HMF intact, GCS 15/15; NFND.

COURSE IN THE HOSPITAL:
A 70 year male presented to the casuality with above mentioned complaints. Necessary investigations were done. Upon initial evaluation he had Hypogastric fullness, foleys was inserted under aseptic condition; He was started on IV Antipyretic medications and Oral hypoglycemic agents. Patient was shifted to AMC after priliminary workup and management.










ECG at presentation:
Chest xray PA view:

USG Abdomen:
Fever Chart:
Investigation Chart:
GRBS TRENDS:
RADIOLOGICAL STUDIES:




TREATMENT:
1. IVF NS/RL @75 ML/HOUR.
2. INJ. NEOMOL 100ML /IV/TID.
3. INJ. ZOFER 4MG/IV/ SOS.
4. SYP. ARYSTOZYME 15ML/PO/TID.
5. GRBS 7• PROFILE.
6. VITAL MONITORING 4TH HOURLY.
7. I/O CHARTING.

Comments

Post a Comment

Popular posts from this blog

Meta AI Driven Thematic Analysis NKP in 50 patients of Cardiovascular disease in ESRD on Dialysis

  Please thematically analyse the case report content below by separately addressing the four points below: Coding:  identify initial codes and labels to capture the key concepts and ideas. Categorization: group the codes into categories and subcategories to organize the data. Theme identification: identify the emerging themes and patterns in the data. Theme representation:  present the themes as learning points, highlighting the key findings and insights related to heart failure outcomes in a patient of renal failure  Dr Kranthi's patient of  40 MALE HYPERTENSIVE CHRONIC KIDNEY DISEASE ON HEMODIALYSIS WITH HFpEF July 01, 2024 An attempt to understand the topic of " Patient clinical data analysis" to develop my competence in reading and comprehending clinical data including history, clinical findings, and investigations and coming up with a diagnosis and treatment plan. DEIDENTIFIED DISCHARGE SUMMARY Age Gender : 40 Years/Male Address Checharge Type: Relieved Admission Da
Read more

DISSERTATION TOPIC

THESIS TITLE: THERAPEUTIC OUTCOMES IN PATIENTS WITH CARDIOVASCULAR DISEASE IN CHRONIC KIDNEY DISEASE. PROBLEM STATEMENT:  CKD is common in patients with heart failure, associated with high mortality and morbidity, which is even higher in people undergoing long-term dialysis. Despite increasing use of evidence-based drug and device therapy in patients with heart failure in the general population, patients with CKD have not benefitted AIM: MANAGING CARDIOVASCULAR DISEASE IN PATIENTS WITH CHRONIC KIDNEY DISEASE. OBJECTIVES:  1. To study the cardiac changes and complications in patients with chronic kidney disease. 2. To improve outcomes in patients having heart failure with CKD. 3. Understanding development LV dysfunction. PATIENTS AND METHODS: PLACE OF STUDY: Kamineni Institute of Medical Sciences and Hospital, Narketpally.   STUDY PERIOD: November 2022 to October 2024. STUDY DESIGN: Prospective study. SAMPLE SIZE : 60. INCLUSION CRITERIA: The following criteria were used in the selectio
Read more

47 year female with abdominal distention

Image
This is an online E logbook 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 a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with collective current best evidence-based inputs. PRESENTING COMPLAINTS: C/O Generalized Itching since a month. C/O Shortness of breath since 10 days. C/O Abdominal pain since 7 days. C/O Lower back pain since 7 days. HOPI: A 47 year female who was a known case of Extrapulmonary TB with Ascites on ATT 21/07/2022; Now presented to the OPD with complaints of Generalized Itching 7- 10 days after starting the ATT regimen. History of shortness of breath not associated with Orthopnea and PND since 10 days. History of gradual painless abdominal distention associated with lower back pain since a week. No history of chest pain, palpitations, bleeding manifestations, f
Read more