62 year old male with loss of appetite,sob and fever 
 CBBLE UDHC similar cases 

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 
62 year male farmer by occupation came with complaints of loss of appetite since 20 days ,sob and fever, since 20 days. Vomiting since 2 days. ,Painful swelling in the left  gluteal region since 2 days and pain in the right hip region
HOPI : patient was apparently asymptomatic 20 days back then he went to outside private hospital with complaints of fever and sob and on investigation his creatinine 5.3 ,so sent for hemodialysis to our hospital.
C/o shortness of breath since 20 days  grade 4 ,no pnd and no orthopnea
Fever treated at outside private hospital 5 days back
Vomitings since 2 days, 2-3 episodes per day, food and water as content ,non projectile.
No decreased urine output.
Pain in the right hip region, pricking type radiating to the gluteal region 
Swelling in the left gluteal region of approximately 3x3 cms, solitary swelling,mobile

PAST HISTORY : 

H/o slip and fall 5 years ago and knee surgery was done and diagnosed with HTN and DM type 2 and he is on irregular medication.
He is diagnosed as ckd 2 years back
and managed conservatively but on irregular medication
Personal history: 
He is a chronic alcoholic and beedi smoker since childhood 6 beedis/day
HRCT done outside:
Areas of cystic bronchiectasis with fibrotic bands and adjacent pleural thickening in right upper lobe 
Fibroatelectatic changes in right upper lobe and right middle lobe
O/E
 pallor+ , no icterus ,clubbing,koilonychia,lymhpadenopathy,pedal edema





X ray chest
grbs charting
X ray hip


Surgery referal

ABG

 Vitals :
Temp:98.4f
Pr:82bpm
SPO2 :98%@ra
Bp:140/90mm hg
Rr :cpm
Grbs :160mg/dl
Treatment:
1 inj augmentin 1.2g iv/od
2 tab Azithromycin 500 mg po/od
3 inj lasix 40mg iv bd
4 tab atenolol 25mg po/od
5 tab nodosis 500mg po/bd
6 tab orofer xt po/bd
7 tab shelcal ct po/odp
8 neb with duolin and budecort @8th hrly
9 tab ultracet 1/2tab qid
10 monitor vitals

Diagnosis: chronic kidney disease secondary to diabetic nephropathy.with htn and DM since 5 years with cystic bronchiectasis , fibrotic bands in both upper lobeslobes right >left with no pleural effusion



Popular posts from this blog

Image
54 YEAR OLD MALE PATIENT WITH DISTENTION OF ABDOMEN, JAUNDICE, BURNING MICTURITION SINCE 15 DAYS   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 an available global online community of experts to solve those patients' 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 in the comment box are welcome. —————————————————————————————————————————————- A 54 YEAR OLD MALE  PATIENT CAME WITH COMPLAINTS OF  1. DISTENSION OF ABDOMEN SINCE 15 DAYS 2. H/O JAUNDICE SINCE 15 DAYS 3.BURNING MICTURITION SINCE 15 DAYS NO H/O FEVER,SOB,PEDAL EDEMA HOPI:  PATIENT WAS APPARENTLY ASYMPTOMATIC 5 MONTHS BACK, ON JAN 2021 PATIENT WAS OPERATED FOR GALL STONES.POST OP NO COMPLICATIONS AND WAS NORMAL .
Read more
Image
 A 35 year old man presented to the casualty with the complaints of  Bilateral pedal edema since 1 week Dyspnea since 15 days  Abdominal distension since 2 months  History of Presenting illness A 35 year old man, who sells plants  at nalgonda tells us a detailed insight to the reason for all his problems. He says he has been married 9 years back but since the past 5 years he has been living apart from his wife and his 2 sons due to marital issues. Prior to that he used to consume alcohol occasionally but since the past 5 years he has been consuming about half to 1 bottle of whiskey everyday. 3 years back, he paid a visit to a local hospital with abdominal distension and pedal edema and he was diagnosed with chronic liver disease for which he used medications for a while and stopped. He was even diagnosed to be a diabetic back then and he started using Tab Metformin 500mg OD. 2 months back, his abdominal distension increased and his eyes became yellow after which he started using local
Read more
Image
62/F came to casualty with c/of pain abdomen since 1 month  Yellowish discoloration of eyes since 15 days  Vomitings since 15 days sob since 15 days  Decreased appetite since 15 days Patient was apparently asymptomatic 1 month back  Had H/of pain abdomen on and off since 1 month - insidious onset, intermittent , diffuse and burning type of pain associated with decreased appetite taking only fluids since 15 days f/by vomitings - bilious, non- projectile, food or water as content whenever patient is taking oral feeds Yellowish discoloration of eyes since 15 days  Sob since 15 days inscidious onset gradually progressed from grade 2 to 3 associated with pedal odema and decrease urine output  not associated with fever, cold, cough, orthopnea and PND No pale coloured stools, mucous , blood or dark coloured stools  0/examination: pt-conscious and tachypnic  Afebrile  Icterus +  No pallor, cyanosis, clubbing, lymphadenopathy PR - 90 bpm  BP- 130/80 mm of hg  RR - 34 cpm  Spo2 -88 with RA  98
Read more