Final exam practical- short case
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
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 15 Yrs back , then patient suddenly fell from toddy tree while climbing ,had history of fracture of femur for which open reduction and internal fixation (ORIF) was done.
Again 10 Yrs back patient had c/o fall due to giddiness, then diagnosed with hypertension and since then on regular medication
Patient Has Got Flexion Fixed Deformities 7 Year Back . Stays In Home and stopped Climbing Toddy Trees .
Patient came with the chief complaint of Anuria since yesterday
SOB Grade- 2-3
Orthopnoea: Negative
PND : Negative
No complaints of chest pain , Palpitations , Syncopial attacks
PAST HISTORY:
Not a known case of DM , CVA ,CAD , TB , ASTHMA
As told by the patient and his attenders
First he had h/o fall from tree 9-10 yrs back,had (femur) ,ORIF was done. He used to walk with support for few months
Then after 5 years he had h/o fall , no treatment was done
Then again he had h/o fall at his home
From then he was unable to walk even with support
TREATMENT HISTORY :
For Hypertension - TAB.AMLONG 5 MG PO / OD
Surgery for renal canaliculi is done
PERSONAL HISTORY :
Appetite- decreased
Bowel - irregular
Micturition - abnormal
Addictions:- consumes alcohol occasionally and history of smoking
FAMILY HISTORY :- not significant
GENERAL EXAMINATION :
Patient is conscious, coherent ,co-operative
Signs of pallor and pedel edema present
No icterus
No clubbing
No cyanosis
No Lymphadenopathy
VITALS :-
TEMPERATURE - 98.6 F
PULSE - 100 BPM
RR - 16 CPM
BP - 160/90 MMHG
Spo2 - 98 % @ ROOM AIR
GRBS: 106MG%
CVS - S1S2 HEARD , NO MURMURS
CNS - INTACT
RS :- DYSPNOEA PRESENT
BREATH SOUNDS - VESICULAR ; B/L IAA , CREPITUS
PER ABDOMEN : SOFT, NONTENDER
ULTRASOUND
ECG
HAEMOGRAM
TPR:
PROVISIONAL DIAGNOSIS
AKI secondary to? Acute urinary retention
TREATMENT PLAN:
Inj. Meropenem 500mg / IV/BD
2) Inj. LASIX 40mg/IV/BD
3 ORAL FLUIDS ~2L.
4) Inj. PAN 40mg /IV/OD
5) Neb with DUOLIN & Budecort 8th hourly
6) Tab. AMLONG 5mg po/OD
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