Final practical short case

 

80 year old male patient with CKD

June 07, 2022


Name: A.Bhavani

Hall ticket number: 1701006004

Batch - 2017

 "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

Chief complaints-

80 years old male patient, agriculture labourer by occupation came to general medicine OPD on 31 St may,2022 with the chief complaints of

 fever - since 3 days

An episode of vomiting 2 days back

Decreased urine output since 2 days 

burning micturition since 2 days

Timeline-



History of presenting illness-

=>patient is apparently asymptomatic 3 days back. 

Then he developped fever

      >insidious in onset 

      > gradually progressive 

      >No diurnal variations 

      >Relieved on medication

> Associated with chills, rigors 

>Has generalised body pains

>It is not associated with cough, cold, shortness of breathe, night sweats.


 =>He had an episode of vomiting 2 days back which consisted of food.It is non bilious and not foul smelling and colour is same as that of food.


=>He developped burning micturition 2 days back which is present at the start of the urinary flow and relieved after the urination.


=> He also developped decreased urine output since 2 days which is not associated with any hematuria.

=>He developped dyspnoea on exertion since 2 days.


Past history-

=>He has similar complaints in the past 10years ago
=>Then he consulted a local doctor and he was given medication.The symptoms were relieved on medication
=>From the past 10 years ,there is recurrence of such episodes 
=>later he was refered to higher hospital and diagnosed with renal problem (AKI) which was treated with dialysis once and  he was given some diuretics as he is suffering from decreased urine output(oliguria)

=>Even after dialysis,he developped recurrent episodes of fever with burning micturition.

=>He is a known case of hypertension since 24years.

=>Not a known case of diabetes mellitus, tuberculosis,asthma and epilepsy.



Surgical history-

=>He underwent nephrectomy surgery 27yrs ago  =>He donated  his left kidney to his brother.


Personal history-

.Diet- mixed

.Appetite - normal

.Sleep - adequate

.Bowel - irregular,didnot pass stools for past 4 days

.Bladder - oliguria since 2 days, associated with burning micturition, feeling of incomplete voiding. 

.Allergies- none

.Addictions- >3 beedi/ day from 27yrs of age

                      >Alcohol- occasionally 

.Stopped both alcohol and smoking after  nephrectomy surgery.


Family history-

=>No similar complaints were present in the family members.

=>No H/O DM,HTN.


General examination-

=>Patient is conscious, coherent, co operative and well oriented to time, place, and person.

 moderately build and moderately nourished.

.Temperature-99.2°F
.Pulse rate-76 beats per minute
.Respiratory rate-19 cycles per mimute
.BP-150/90 mm of Hg
.GRBS-78 mg/dl
.SpO2-99% at room air

.Pallor- present
.Icterus-absent
.cyanosis- absent
.Clubbing- absent
.Lymphadenopathy- absent
.Edema- present( gradually progressive,pitting type,bilateral,grade-2,below knee present upto ankle region from below)
>Not relieved on rest








Systemic examination

cardio vascular examination

       =>  No visible pulsations, scars, engorged veins. No rise in jvp

       =>Apex beat is felt at left 5th intercostal space medial to mid clavicular line.

       =>S1 S2 heard . No murmurs.

- Respiratory system

      => Shape of chest is elliptical, biIlaterally symmetrical.

          => Trachea is central. Expansion of chest is symmetrical

          =>Bilateral Airway entry - positive

    Per abdomen examination-

=> No visible pulsations and scars,sinuses and     swellings. 

     =>No abdominal distension

     => Soft, non tender, no organomegaley.

     =>Umbilicus is inverted. 




CNS EXAMINATION: 

.Conscious 

.Speech- normal

.Cranial nerves: normal

.Sensory system: normal

.Motor system: normal

.Reflexes- Right    Left

Biceps      ++          ++

Triceps    ++          ++

Supinator ++         ++

Knee        ++        ++

Ankle        ++         ++

.Gait-normal

Provisional Diagnosis:
Acute (secondary urosepsis) on chronic kidney disease might be due to recurrent urinary track infection.

Investigations.

Complete blood picture-

On 31/05/2022,4.36 pm-


On 31/05/2022,11.03pm-


Hemogram-

On 01/06/2022-


On 02/06/2022-


On 03/06/2022-

Hemoglobin - 6.6 gm/dl
Increased WBC count- 19,900

RFT-

Urea - 129 mg/dl
Creatinine- 6.3 mg/dl
Complete urine examination-


       Urine - pus cells (plenty) 

Blood urea-



Serum electrolytes-

Serum creatinine- 

Random blood sugar-


Liver function tests-









USG report: 
1)Raised echo genicity of right kidney
2) normal size of kidney
3) mild hydronephrosis
4) not visible left kidney


ECG  REPORT

Serum iron-

Treatment:

1)Inj. Piptaz -2.25gm/tid

2)Tab. Lasix -40ug/po/ bd

3)Tab. Zofer -4mg/po/ sos

4)Tab. Dolo -650/ po/ sos

5)Tab. Pan 40mg /po/ od

6)Nebi. Duolin and Budecort 6hrly

7)Syr. Mucaine gel 15ml/po/ bd before meal 15min

8)Syrup. Cremaffin 15ml/po/ sos.







01/06/2022-

Patient is conscious,coherent and cooperative.moderately built and moderately nourished.

.Temperature-99.2°F
.Pulse rate-76 beats per minute
.Respiratory rate-19 cycles per mimute
.BP-150/90 mm of Hg
.GRBS-78 mg/dl
.SpO2-99% at room air

Treatment:

1)Inj. Piptaz -2.25gm/tid

2)Tab. Lasix -40ug/po/ bd

3)Tab. Zofer -4mg/po/ sos

4)Tab. Dolo -650/ po/ sos

5)Tab. Pan 40mg /po/ od

6)Nebi. Duolin and Budecort 6hrly

7)Syr. Mucaine gel 15ml/po/ bd before meal 15min

8)Syrup. Cremaffin 15ml/po/ sos.


02/06/2022-

Patient is conscious,coherent and cooperative.moderately built and moderately nourished.

.Temperature-98.6°F
.Pulse rate-90 beats per minute
.Respiratory rate-20 cpm
.BP-130/70 mm of Hg
.GRBS-148 mg/dl
.SpO2-99% at room air

Treatment:

1)Inj. Piptaz -2.25gm/tid

2)Tab. Lasix -40ug/po/ bd

3)Tab. Zofer -4mg/po/ sos

4)Tab. Dolo -650/ po/ sos

5)Tab. Pan 40mg /po/ od

6)Nebi. Duolin and Budecort 6hrly

7)Syr. Mucaine gel 15ml/po/ bd before meal 15min

8)Syrup. Cremaffin 15ml/po/ sos.


03/06/2022-

Patient is conscious,coherent and cooperative.moderately built and moderately nourished.

.Temperature-99.6°F
.Pulse rate-94 beats per minute
.Respiratory rate-20 cpm
.BP-110/70 mm of Hg
.GRBS-132 mg/dl
.SpO2-99% at room air

Treatment:

1)Inj. Piptaz -2.25gm/tid

2)Tab. Lasix -40ug/po/ bd

3)Tab. Zofer -4mg/po/ sos

4)Tab. Dolo -650/ po/ sos

5)Tab. Pan 40mg /po/ od

6)Nebi. Duolin and Budecort 6hrly

7)Syr. Mucaine gel 15ml/po/ bd before meal 15min

8)Syrup. Cremaffin 15ml/po/ sos


04/06/2022-

Patient is conscious,coherent and cooperative.moderately built and moderately nourished.

.Temperature-98.6°F
.Pulse rate-89beats per minute
.Respiratory rate-20 cpm
.BP-130/90 mm of Hg
.GRBS-122 mg/dl
.SpO2-98% at room air

Treatment:

1)Inj. Piptaz -2.25gm/tid

2)Tab. Lasix -40ug/po/ bd

3)Tab. Zofer -4mg/po/ sos

4)Tab. Dolo -650/ po/ sos

5)Tab. Pan 40mg /po/ od

6)Nebi. Duolin and Budecort 6hrly

7)Syr. Mucaine gel 15ml/po/ bd before meal 15min

8)Syrup. Cremaffin 15ml/po/ sos


05/06/2022-

Patient is conscious,coherent and cooperative.moderately built and moderately nourished.

.Temperature-98.6°F
.Pulse rate-86 beats per minute
.BP-150/90 mm of Hg


Treatment:

1)Inj. Piptaz -2.25gm/tid

2)Tab. Lasix -40ug/po/ bd

3)Tab. Zofer -4mg/po/ sos

4)Tab. Dolo -650/ po/ sos

5)Tab. Pan 40mg /po/ od

6)Nebi. Duolin and Budecort 6hrly

7)Syr. Mucaine gel 15ml/po/ bd before meal 15min

8)Syrup. Cremaffin 15ml/po/ sos


06/06/2022-


Patient is conscious,coherent and cooperative.moderately built and moderately nourished.

.Temperature-99.2°F
.Pulse rate-86 beats per minute
.BP-150/90 mm of Hg


Treatment:

1)Inj. Piptaz -2.25gm/tid

2)Tab. Lasix -40ug/po/ bd

3)Tab. Zofer -4mg/po/ sos

4)Tab. Dolo -650/ po/ sos

5)Tab. Pan 40mg /po/ od

6)Nebi. Duolin and Budecort 6hrly

7)Syr. Mucaine gel 15ml/po/ bd before meal 15min

8)Syrup. Cremaffin 15ml/po/ sos


07/06/2022-


Patient is conscious,coherent and cooperative.moderately built and moderately nourished.

.Temperature-afebrile
.Pulse rate-84 beats per minute
.BP-130/90 mm of Hg


Treatment:

1)Inj. Piptaz -2.25gm/tid

2)Tab. Lasix -40ug/po/ bd

3)Tab. Zofer -4mg/po/ sos

4)Tab. Dolo -650/ po/ sos

5)Tab. Pan 40mg /po/ od

6)Nebi. Duolin and Budecort 6hrly

7)Syr. Mucaine gel 15ml/po/ bd before meal 15min

8)Syrup. Cremaffin 15ml/po/ sos


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