General medicine E-log

 2 nd December,2021.

This is an online E-log book to discuss our patients de-identified health data shared after taking his 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 patient's with collective current best evidence based inputs.

A.Bhavani

Roll.no-150

I've 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.

DEC 2nd,2021

56 YEAR OLD MALE WITH URINARY TRACT INFECTION

CASE DISCUSSION:-

A 56 year old male ,presented to the OPD on 1st December with chief complaints ofChief complaints of

 ->High grade fever since 3 days

 -> Burning micturation since 3 days

 ->Lower back pain since 3 days

HISTORY OF PRESENT ILLNESS:-

 ->4 yrs ago Pt. had fever. Fever was low garde ,associated with chills . 

->Burning micturition since 4 years,which is on and off.Burning is present only during voiding.

 ->4 years ago he was admitted in our hospital and diagnosed with Diabetes mellitus and he underwent dialysis once.

->he is on medication for DM since 2 yrs (H.Actrapid )

-High grade fever with chill since 3 days  associated with burning micturition

- Decreased urine output since 3 days 

- History of vomiting - food as content and billious vomiting since 2 days 

- SOB since 3 days 

- lower back pain since 3 days 

- no complqin of cough , loose stools ,            rashes , body pain , pedal edema 

HISTORY OF PAST ILLNESS :-

- known case of DM since 4 years , on      injection Human ACTRAPID since 2 years 

-was informed to have kidney disease,not on any medication.

- not a known case of HTN , CAD 

PERSONAL HISTORY :-

Diet : Veg 

Appetite : normal 

Bowel movement regular 

Burning micturition 

Occassional alcoholic 

Sleep disturbed 

GENERAL EXAMINATION:-

Patient was examined in well lit room with his consent .

Patient is conscious ,coherent and cooperative 

Patient is well oriented to time and place

Moderately built and nourished

Pallor:absent

Icterus: absent

Clubbing:absent

Cyanosis:absent

Lymphadenopathy: absent

Edema: absent

VITALS:-

Temperature: 99.3 F

Pulse: 92 / min

Respiratory rate : 25 bpm

Blood pressure : 120/80 mmHg

SpO2 at room air : 98 per cent 

GRBS : 180 mg/dL

SYSTEMIC EXAMINATION :-

Cardiovascular system

-s1 and s2 heard ,no murmurs 

Respiratory system

-Central position of trachea 

-Vesicular breath sounds

-No wheeze,no dyspnea

Abdominal examination

-Scaphoid shape

-No tenderness

-No palpable masses

 -bowel sounds heard 

-No organomegaly

CNS Examination 

-No FND 

PROVISIONAL DIAGNOSIS:-

1)UTI

2)AKI on ?CKD

3) Thrombocytopenia

INVESTIGATIONS:-

On 1/12/2021

On 2/12/2021

Outside reports:-

On 2/12/2021:-

PH-7.34

PCO2-24.4mmHg

PO2-74.8mmHg

SO2-94.3%

RBS-99mg/dl

HCO3-13.1mEq/L

Dengue-negative

RT-PCR-negative

CUE:-

Pus cells- 3 to 4

Epithelial cells-2 to 3

RBC-nil

FBS-89mg/dl

PLBS-108mg/l

Hb- 14.4 mg/dl

TLC- 7390

PLT- 55,000

BGT- O Positive

Serum Urea- 94

Serum Creatinine- 3.1

Serum Uric Acid- 7.1

Na- 141

K- 4.2

Cl- 102

Total Bilirubin- 4.44

Direct Bilirubin- 2.24

AST- 52

ALT- 22

ALP- 103

TP- 5.5

ALB- 3.3

A/G- 1.61

PT-16

APTT-31

TREATMENT:-

1)IVF- 2NS, 2RS @75ml/hr

2)Inj.Pantop 40 mg IV OD

3)Inj.Zofer 4 mg IV BD

4)syp.Citralka 10 ml in 1 glass of water PO BD

5)GRBS- 6th hourly(8am-2pm-8pm-2am)

6)Inj.Human Antrapid SC TID

7)BP,HR,SPO2 charting

8)Tab.Dolo 650 mg PO TID

9)Inj.Neomol 1 gm IV (if temp >101F)

10) Temperature charting 4th hourly

11)Plenty of oral fuids

12)Strict I/O charting

13)Inj.Ciprofloxacin 200 mg IV BD

14) Syp.Aristrozyme 10 ml PO BD

15)Syp.Sucralfate 10 ml PO BD