A 70 yr old female with SOB

  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.

CHIEF COMPLAINTS 

70 year old female came  to OPD with c/o 

              •  SOB  since 10 days which was aggravated in the last 3 days (grade 4)

                • Fever since 10 days.

               • Decreased urine output since 5 days

               •  Burning micturition since 5 days.  

               •  Loss of appetite since 6 days.

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 10 days back then she developed fever which is low grade intermittent in nature associated with chills and rigor and is relieved on medication. SOB since 10 days which was aggravated in the last three days to grade 4.

Patient complaints of burning micturition and decrease urine output since 5 days.

Patient was taken to hospital 8 days back and was diagnosed as typhoid and was treated for the same.








PAST HISTORY 

Patient is k/c/o DM type 2 since 15 years using 

T. Metformin 500mg PO/ OD .

She is also a k/c/o Hypertension since 10 years and uses T. Telma (40 or 12.5) mg PO/OD .

She is not a k/c/o asthma , epilepsy,  TB.

PERSONAL HISTORY

She consumes mixed diet

Appetite is decreased in the past 6 days

Sleep is adequate

Bowel regular and decrease in urine output.

No addictions.

FAMILY HISTORY

Not Significant.

GENRAL EXAMINATION

The patient is coherent, conscious,cooperative well oriented to time place and person 

She is well built and nourished 

PALLOR -absent 

ICTERUS -absent 

CYANOSIS -absent 

CLUBBING -absent 

EDEMA -absent 

LYMPHADENOPATHY -absent 

VITALS :-

On the day of admission

TEMP-98.9f

PR-90bpm

RR -20cpm

BP-130/90mm hg

Spo2-98%

Grbs -230 mg/ dl


SYSTEMIC EXAMINATION 

CVS-S1S2 heard 

CNS-Higher motor functions intact 

PA-Soft and non tender 

RS- BAE+

FEVER CHART



ECG



INVESTIGATIONS











PROVISIONAL DIAGNOSIS

AKI on CKD

TREATMENT 

Rx

Head End Elevation upto 30°

Inj PIPTAZ 2.25 gram IV/ BD

Inj. Neomal 1gm Iv SOS if temp > 101F

T. Lasix 40mg PO/BD if SBP> 110mm hg

T. Nodosis 500 mg. PO/ TID

T. Orofer XT PO/ OD

T. Shelcal 500 mg PO/OD 

T. PCM 500 mg PO /SOS 

Cap Bio D3 PO /  weekly twice.

BP monitoring every 2 hours

Fever charting every 6 hours

Vitals monitoring every 4th hourly.





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