General medicine case 2
This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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.
Date of admission : 16th August 2021
A 70 year old male presented to the OPD with the chief complaint of fever, low urine output, back ache and shortness of breath since 10 days.
History of present illness :
- Patient was apparently asymptomatic 4 years back then he developed shortness of breath, pedal edema for which he was admitted to hospital.
- He was treated for the above condition.
- 3 years back he developed back pain which was intermittent and was on medication
- since 2 months he had fever, back pain
- since 1 month he developed shortness of breath and pedal edema
History of past illness :
- He is a known case of hypertension since one year
- He was diagnosed with TB 20 years back.
Personal history :
- The patient has loss of appetite
- He takes mixed diet
- He has constipation, decreased urine output with burning micturition
- He is a known case of chutta smoking 4/5 per day and was alcoholic but stopped them 3 years back
- Low socio-economic status
Family history :
- There is no history of DM, hypertension, CAD, CVA or similar complaints in the family.
Treatment history :
- The patient used pain killers for back ache
- No history of drug allergy
General examination :
- Patient is conscious, coherent, cooperative
- Pallor is present
- No cyanosis
- No icterus
- No clubbing of fingers or toes
- No lymphadenopathy
- Bilateral pedal edema present
Vitals : temperature - 98.6 F
Pulse rate - 85
Respiratory rate - 20 cycles per minute
Spo2 - 98%
BP - 130/70 mm Hg
Systemic examination :
CVS
Inspection - chest wall is bilaterally symmetrical
- No precordial bulge
- No visible pulsations, engorged veins, scars, sinuses
Palpation - JVP is normal
Auscultation - S1 and S2 heard
RESPIRATORY SYSTEM
- Position of trachea is central
- Bilateral air entry us normal
- Normal vesicular breath sounds heard
- No added sounds
PER ABDOMEN
- abdomen is not tender
- bowel sounds heard
- no palpable mass or free fluid
CNS
- Patient is conscious
- Speech is present
- Reflexes are normal
Provisional diagnosis : CFR, viral thrombocytopenia
Investigations : On 16th August -
Hemogram :
Hemoglobin : 10.5 gm/dl
Total count : 6200 cells/cumm
Neutrophils : 71%
Lymphocytes : 16%
Eosinophils : 3%
Monocytes : 10%
Basophils : 0%
Platelet count : 1.0 lakh /cumm
Smear : normocytic normochromic anemia with thrombocytopenia
On 18th August
Hemoglobin : 10.2 gm/dl
Total count : 7400 cells/cumm
Neutrophils : 79%
Lymphocytes : 09%
Eosinophils : 02%
Monocytes : 10%
Basophils : 0%
Platelet count : 40,000 cumm
Smear : normocytic normochromic with thrombocytopenia
On 19th August
Hemoglobin : 9 gm/dl
Total count : 15,900 cells/cumm
Neutrophils : 92%
Lymphocytes : 4%
Eosinophils : 1%
Monocytes : 3%
Basophils : 0%
Platelet count : 40,000 per cumm
Smear : microcytic hypochromic anemia with neutrophilic leucocytosis and thrombocytopenia
On 20th August
Hemoglobin : 7.9
Total count : 17,400
Neutrophils : 88
Lymphocytes : 3
Eosinophils : 1
Monocytes : 8
Basophils : 0
Platelet count : 76000
Smear : microcytic hypochromic anemia with nuetrophiluc leucocytosis with thrombocytopenia
On 21st August
Hemoglobin : 7.8
Total count : 20,000
Neutrophils : 88
Lymphocytes : 6
Eosinophils : 1
Monocytes : 5
Basophils : 0
Platelet count : 92,000
Smear : normocytic normochromic anemia with neutrophilic leucocytosis and thrombocytopenia
On 22nd August
Hemoglobin : 7.2
Total count : 11,000
Neutrophils : 89
Lymphocytes : 3
Eosinophils : 2
Monocytes : 6
Basophils : 0
Platelet count : 1.20 lakh/cumm
Smear : microcytic hypochromic anemia with neutrophilia and thrombocytopenia
Final diagnosis : acute kidney injury
TREATMENT:
Day 0
Patient had no new complaints
His vitals are :
Temp-98.6F BP: 130/70mmHg PR:85bpm RR:20cpm
- inj lasix 40 mg IV TID
- tab nodosis 500 mg TID
- tab shelcal 500 mg OD
- tab orofer xt BD
- tab Amlong 5mg OD
- neb with duoline 8th hourly and budecort 12th hourly
Vitals are being monitored 4th hourlyG, RBS 8th hourly
Day 1
Patient had no new complaints
His vitals are
Temp : 98.6F BP: 120/70mmHg PR: 82bpm RR:19cpm
GRBS: 120mg/dl
- inj lasix 40 mg IV TID
- tab nodosis 500 mg TID
- tab shelcal 500 mg OD
- tab orofer xt BD
- tab Amlong 5mg OD
Day 2
Patient had no new complaints
His vitals are
Temp: 98.7F BP: 120/70mmhg PR: 84bpm RR: 24cpm
GRBS : 162mg/dl
- inj lasix 40 mg IV TID
- tab nodosis 500 mg TID
- tab shelcal 500 mg OD
- tab orofer xt BD
- tab Amlong 5mg OD
Neb given with Dublin
Day 3
Patient had no new complaints
His vitals are
Temp: 98.6F BP: 120/80mmHg PR: 82bpm RR: 22cpm
GRBS : 95mg/dl
-inj lasix 40mg IV BD
-inj pan 40mg IV OD
-inj cepraxone 1gm IV BD
- tab Nodosis 500mg TID
-tab Orofer xt BD
-tab Amlong 5mg OD
-tab shelcal 500mg OD
Neb with ipravent 8th hourly and with budecort 12th hourly
Day 4
Patient had no new complaints
His vitals are
Temp: 97.8F BP: 120/80mmHg PR: 90bpm RR: 22cpm
GRBS : 119mm/dl
inj pan 40mg IV OD
-inj cepraxone 1gm IV BD
- tab Nodosis 500mg TID
-tab Orofer xt BD
-tab Amlong 5mg OD
-tab shelcal 500mg OD
Neb with ipravent 8th hourly and with budecort 12th hourly
Day 5
Patient had no new complaints
His vitals are
Temp: 98.6F BP: 80/60mmHg PR: 64bpm RR: 23cpm
GRBS : 160mg/dl
-inj pan 40mg IV OD
-inj cepraxone 1gm IV BD
-inj zoper 4ml BD
- tab Nodosis 500mg BD
-tab Orofer xt BD
-tab Amlong 5mg OD
-tab shelcal 500mg OD
Neb with ipravent 8th hourly and with budecort 12th hourly
Day 6
Patient had no new complaints
His vitals are
Temp: 98.6F BP: 130/80mmHg PR : 92bpm RR: 21cpm
GRBS: 140mg/dl
-inj pan 40mg IV OD
-inj cepraxone 1gm IV BD
-inj zoper 4ml BD
- tab Nodosis 500mg BD
-tab Orofer xt BD
-tab Amlong 5mg OD
-tab shelcal 500mg OD
Neb with ipravent 8th hourly and with budecort 12th hourly
Day 7
Patient had no new complaints
His vitals are
Temp: 98.6F BP: 100/80mmhg PR: 90bpm RR : 21 cpm
GRBS : 130mg/dl
-inj lasix 40mg IV BD
-inj pan 40mg IV OD
-inj cepraxone 1gm IV BD
-inj zoper 4ml BD
- tab Nodosis 500mg BD
-tab Orofer xt BD
-tab Amlong 5mg OD
-tab shelcal 500mg OD
Neb with ipravent 8th hourly and with budecort 12th hourly
- patient underwent dialysis 3 times on 18th, 20, 21st August
- patient has altered speech since he is undergoing dialysis
What would be the treatment for altered speech ?
Could this be due to analgesics he was using for past few years ?
Comments
Post a Comment