A 65/M with backache and burning micturition since 5 days.

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 is welcome.
Here is a case i have seen:  

A 65 year old male patient farmer by occupation came to OP with complaints of  backache and burning micturition since 5 days,fever since 5 days
Patient was apparently asymptomatic 5 years back Then he had complaints of fever sudden in onset low grade type, Sweating and giddiness for which he went to local hospital where he was diagnosed with Hypertension and DM II.
Then,9 months ago He underwent jaboulay's surgery for Hydrocoele.Later 8 months ago,He devloped sudden weakness of right upper limb and was taken to hospital ,CT brain was done which came to be normal and was adviced physiotherapy due to which patient symptoms relieved within 2 weeks.
Now , patient came with complaints of fever since 5 days, insidious in onset, intermittent not associated with chills and rigor,no aggrevating features but relieved on medication,No diurnal variations. No H/O cold,cough,recent throat infection.H/O backache and burning micturition since 5 days No H/O night sweats, giddiness, weight loss.
Mixed diet, Appetite normal, Adequate sleep, regular Bowel movements,Occasionally alcohol consumption since 25 years(90-180ml) but daily consumption since 10 days.Chronic Smoker - 18beedis/day.
General Examination: 
Patient is conscious, coherent, cooperative, moderately built and moderately nourished.
No pallor ,Icterus, Cyanosis, Clubbing lymphadenopathy and pedal edema.
Vitals : temp -98.6F, PR-84bom,BP -140/90mmHg,RR-18cpm.
CVS : S1 S2 heard,no murmurs.
RS : BLAE+,NVBS+.
CNS : NAD.
P/A : soft ,non tender.


Investigations :
Provisional Diagnosis: 
Urosepsis with AKI K/C/O HTN,DM II.
Treatment :

Day 1-
INJ.PANTOP 40mg IV OD
INJ.PIPTAZ 2.25gm IV QID
IVF.NS @ 150ml/hr
IVF.RL @ 150ml/hr
INJ.HAI S/C after informing to PG
TAB. AMLONG 5 mg OD 8am
TAB.PCM 500 mg SOS
Monitor GRBS 4th hrly
Monitor Temp/BP/PR 4th hrly.

Day 2-
INJ.PANTOP 40mg IV OD
INJ.PIPTAZ 2.25gm IV QID
INJ.NPH 12IU 
INJ.Regular HAI 12IU
TAB. AMLONG 5 mg OD 8am
TAB.PCM 500 mg SOS 
Monitor GRBS 6th hrly.
Withhold OHA till further orders.

Day 3-
INJ.PANTOP 40mg IV OD
INJ.PIPTAZ 2.25gm IV QID
INJ.NPH at 8am-12IU and 8pm-12IU.
INJ. HAI :12IU 8am-12IU ,2pm-12IU,8pm -12IU
TAB. AMLONG 5 mg OD 8am
TAB.PCM 500 mg SOS
SYP.CREMAFFIN 15ml PO BD
Monitor GRBS 6th hrly.

Day 4 -
INJ.PANTOP 40mg IV OD
INJ.PIPTAZ 2.25gm IV QID
INJ.NPH at 8am-14IU and 8pm-14IU.
INJ. HAI :12IU 8am-16IU ,2pm-16IU,8pm -16IU
TAB. AMLONG 5 mg OD 8am
TAB.PCM 500 mg SOS
SYP.CREMAFFIN 15ml PO BD
Monitor GRBS 6th hrly.

Day 5-
INJ.PANTOP 40mg IV OD
INJ.PIPTAZ 2.25gm IV QID
INJ.NPH at 8am-14IU and 8pm-14IU.
INJ. HAI :12IU 8am-16IU ,2pm-16IU,8pm -16IU
TAB. AMLONG 5 mg OD 8am
TAB.PCM 500 mg SOS
SYP.CREMAFFIN 15ml PO BD
Monitor GRBS 6th hrly.

Day 6-
INJ.PANTOP 40mg IV OD
INJ.PIPTAZ 2.25gm IV QID
INJ.NPH at 8am-14IU and 8pm-14IU.
INJ. HAI :12IU 8am-16IU ,2pm-16IU,8pm -16IU
TAB. AMLONG 5 mg OD 8am
TAB.PCM 500 mg SOS
SYP.CREMAFFIN 15ml PO BD
Monitor GRBS 6th hrly.











Popular posts from this blog

Bimonthly Assignment

Image
) A 55 year old man with Recurrent Focal Seizures casehttp://ushaindurthi.blogspot.com/2020/11/55-year-old-male-with-complaints-of.html 1. What is the problem representation of this patient and what could be the anatomical site of lesion ? A 55 year old male came with A--1)Involuntary movements of right upper and lower limbs. 2)Right upper limb weakness 3)DM II 4)Chronic alcoholic and chronic smoker since 35 years. O/E :Clubbing +, bilateral Inspiratory crepts in all areas. B-- right temporal lobe epileptogenic focus.   2. Why are subcortical internal capsular infarcts more common that cortical infarcts? subcortical infarcts are more common than cortical infarcts because the penetrating arteries which supply them have small diameter and  arise from major arteries of greater volume at a certain angle that makes them more prone for occlusion and rupture.Thus making sub cortical infarcts more common.  3. What is the pathogenesis involved in cerebral infarct related seizures? 
Read more

A 70/M potmaker by occupation with SOB since 3 months and B/L pedal edema since 2 months

Image
 70 year old male patient potmaker by occupation presented with C/O SOB since 3 months,B/L Lower limb swelling since 3 months Patient was apparently asymptomatic 30 years ago then he developed sudden  edema  of right upper limb involving upto elbow non pitting type then he had H/O thorn prick over the right palmar region 15 days ago due to which his edema of the right limb increased and was associated with pain but relieved on medication. H/O scrotal swelling since 20 years initially right sided gradual in onset   approximately a size of tennis ball ,got progressed to present size not associated with pain and appears to be B/L presently .3 months back patient developed SOB and got up from sleep in the night time. Since then he had SOB of grade III relieved on taking rest. Later he  observed B/L  pedal edema, pitting type intilally involving upto ankle joint  later progressed upto thigh region since  2 months. No H/O fever, chest pain, palpitations. K/C/O HTN since 3 months and on medic
Read more

A 22 year old male with seizures

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 inputs on the comment box is welcome. Here is a case i have seen: A 22 year old male patient,delivery boy by occupation came with C/O  headache since 2 months and involuntary stiffness of both upper and lower limbs 1 week ago lasting for 2 min associated with LOC. HOPI: patient was apparently asymptomatic  2 months  ago later he developed headache in the occipital region radiating to frontal region which was sudden in onset,progressive, associated with vomiting with food as content ,eye pain and neck pain,
Read more