Final general medicine short case

 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 


9th February 2022
A 65 YEAR OLD MALE PATIENT PRESNTED TO THE OPD WITH C/O ANURIA SINCE 2 DAYS.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 15 Yrs back , then patient suddenly fell from toddy tree while climbing ,had history of fracture of femur for  which open reduction and internal fixation (ORIF) was done.
Again 10 Yrs back patient had  c/o fall  due to giddiness, then  diagnosed with hypertension and since then on regular medication
Patient Has Got Flexion Fixed Deformities 7 Year Back . Stays In Home and stopped Climbing Toddy Trees .

Patient came with the chief complaint of Anuria since  yesterday  
SOB Grade-  2-3
Orthopnoea: Negative
PND : Negative

No complaints of chest pain  , Palpitations , Syncopial attacks


PAST HISTORY: 
Not a known case of DM , CVA ,CAD , TB , ASTHMA

As told by the patient and his attenders
First he had h/o fall from tree 9-10 yrs back,had (femur) ,ORIF was done. He used to walk with support for few months
Then after 5 years he had h/o fall , no treatment was done
Then again he had h/o fall at his home
From then he was unable to walk even with support


TREATMENT HISTORY : 
For Hypertension - TAB.AMLONG 5 MG PO / OD

Surgery for renal canaliculi is done 


PERSONAL HISTORY :
Appetite- decreased
Bowel - irregular
Micturition - abnormal
Addictions:- consumes alcohol occasionally and history of smoking

FAMILY HISTORY :- not significant

GENERAL EXAMINATION : 
Patient is conscious, coherent ,co-operative
Signs of pallor and pedel edema present
No icterus
No clubbing
No cyanosis
No Lymphadenopathy


VITALS :-
TEMPERATURE - 98.6 F
PULSE - 100 BPM
RR - 16 CPM
BP - 160/90 mmHg
Spo2 - 98 % @ ROOM AIR
GRBS: 106Mg%

CVS - S1S2 HEARD , NO MURMURS
CNS - INTACT
RS :- DYSPNOEA PRESENT 
BREATH SOUNDS - VESICULAR ; CREPITUS 
PER ABDOMEN : SOFT, NONTENDER 

INVESTIGATIONS : 


ULTRASOUND 

                


ECG


HAEMOGRAM 

PROVISIONAL DIAGNOSIS

AKI secondary to? Acute urinary retention

TREATMENT PLAN: 
Inj. Meropenem 500mg / IV/BD

2) Inj. LASIX 40mg/IV/BD

3 ORAL FLUIDS ~2L.

4) Inj. PAN 40mg /IV/OD

5) Neb with DUOLIN & Budecort 8th hourly

6) Tab. AMLONG 5mg po/OD

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