75 YEARS OLD MALE WITH COMMUNITY ACQUIRED PNEUMONIA WITH CHRONIC KIDNEY DISEASE

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 comments on comment box is welcome.


MEDICINE CASE DISCUSSION:

I've 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 a diagnosis and treatment plan.


VIEW OF THE CASE :

A 75 years old male came with the cheif complaints of shortness of breathe since 5 hours, loose stools of 3 episodes from today and fever since 6 days.


HISTORY OF PRESENT ILLNESS:

Patient was a mason by occupation and stopped doing work since 10 years. He was normal with his daily routine 6 days back, then he developed fever of low grade , intermittent, releived on taking medication and not associated with any chills and rigors.

He had constipation for 2 days and received DULCOLEX tablets and developed loose stools of 3 episodes. 

From 5 hours, he is having shortness of breathe of grade 3 and often irritable. 



PAST HISTORY:

He is a known case of Hypertension since 1 year. And receiving TAB. AMLODIPINE 5mg .

He is diagnosed for TUBERCULOSIS 30 years back and took treatment for 2 years.

He is not a known case of diabetes, asthma, epilepsy 

1 year back, because of repeated falls, went to government hospital initially diagnosed as hypotensive and after 5 months he was diagnosed as hypertensive and started medications for that.

1 year back, he had pedal edema and shortness of breathe, diagnosed as renal failure and received conservative treatment fo 4 months and stooped medications. Only TAB. NODOSIS is continued till now.


PERSONAL HISTORY:

Appetite- decreased appetite since suffering from fever

Diet- mixed

Bowel habits- loose stools of 3 episodes 

Bladder habits- regular

Sleep- disturbed due to dyspnea 

Addictions- 

Smoking- 18 beedi/day smoked for 30 years and stopped smoking after diagnosed as tuberculosis. 

Alcohol- takes 90ml/day and stopped taking regularly 1 year back and taking occasionally on social gatherings. 

Allergies- no allergies


FAMILY HISTORY:

Insignificant 


GENERAL EXAMINATION:

Conscious and irritable

Pallor- no pallor

Icterus- no icterus

Cyanosis- no cyanosis 

Clubbing- no clubbing 

Generalised lymphadenopathy-no generalised lymphadenopathy 

Pedal edema- no pedal edema


VITALS:

Temperature- 98.4°F

Pulse rate- 92bpm

Respiratory Rate- 22/min

Blood Pressure- 150/70 mm Hg 

SpO2- 90%

GRBS- 120mg%





SYSTEMIC EXAMINATION: 

CARDIOVASCULAR SYSTEM:

First and second heart sounds heard and no murmurs.


RESPIRATORY SYSTEM:

Dyspnea- present of 3rd grade

Wheeze - present 

Vesicular breath sounds 

Rhonchi heard at right infra axillary area

CENTRAL NERVOUS SYSTEM:

Conscious 

Speech- normal 

No neck stiffness and kernings sign is negative

Cranial nerves, motor and sensory systems are normal



PER ABDOMEN EXAMINATION:

shape - scaphoid

No tenderness 

No palpable mass

No hernial orifices

No bruits

No palpable liver and spleen



INVESTIGATIONS:

HEMOGRAM 






COMPLETE URINE EXAMINATION 





RANDOM BLOOD SUGAR 



SERUM UREA



SERUM CREATININE 



SERUM ELECTROLYTES



LIVER FUNCTION TEST 



ARTERIAL BLOOD GAS




ELECTROCARDIOGRAPHY 



CHEST X RAY


ULTRASONOGRAPHY:



2D ECHO RADIOGRAPHY:


SEROLOGY:


                                        












DIAGNOSIS:

COMMUNITY ACQUIRED PNEUMONIA OF LEFT LOBE WITH CKD WITH HYPERTENSION 




TREATMENT:

  1. INJ. AUGMENTIN 1.2mg/IV/BD
  2. TAB. AZITHROMYCIN 500mg /PO/BD
  3. HEAD END ELEVATION 
  4. OXYGEN SUPPLEMENTATION IF SPO2 <90%
  5. FLUID RESTRICTION <1 LITRE/DAY
  6. SALT RESTRICTION <2.4GRAM/DAY
  7. TAB. AMLODIPINE 5mg/PO/OD
  8. TAB. NODOSIS 500mg /PO/OD
  9. NEB WITH DUOLIN 6TH HOURLY,  BUDECORT 6TH HOURLY 
  10. INTERMITTENT CPAP 2ND HOURLY 
  11. TAB. DOLO 650mg /PO/SOS
  12. MONITOR VITALS 4TH HOURLY 
  13. TEMPERATURE CHARTING 4TH HOURLY 
  14. STRICT INPUT/OUTPUT CHARTING 

















Comments

Post a Comment

Popular posts from this blog

Internship

 MY INTERNSHIP JOURNEY IN GENERAL MEDICINE  I'm an intern, posted in general medicine department for 2 months including 2 weeks of psychiatry. First 2 weeks: Posted in Department of Psychiatry: Attended the OPD in department of psychiatry and observed various spectrum of psychiatric disorders in the patients. Studied symptomatology regarding various psychiatric disorder spectrums.  I got to know about the ICD-10 Classification of psychiatry disorders and also DSM Classification of diseases. Done night duties for observation of psychiatry patients of withdrawal syndromes. And learnt how to manage them. Attended the De addiction centre visits and observed the various types of medical, behavioural therapy going on there.  Learnt how to attend rounds for the patients and how to write repeats in the casesheets from post graduates. Typed, studied and submitted the discharge summaries of various patients under department of psychiatry. From this I learnt how to discharge a patient with pr
Read more

15 YEAR OLD MALE WITH ACUTE KIDNEY INJURY

Image
 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 Presenting complaints : A 15 yr old male ,studying 9 th class came to the casuality with C/O SOB( grade 2 - 3 ) since yesterday ,orthopnea +   HOPI : Pt was apparently asymptomatic 1 month back ,pt complains of
Read more

50 YEARS OLD MALE WITH WEAKNESS OF RIGHT UPPER LIKB AND LOWER LIMB

Image
 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 comments on 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. Presenting complaints: Patient came with the cheif complaints of weakness of right upper and lower limb since yesterday morning (04:00am) slurring of speech and deviation of mouth to lef
Read more