Medicine case presentation

Hello all...  I am an  intern in medicine department. I am here to present a case history of one of our patient who got admitted. This is to complete my log book as a part of internship.

    

   CASE DISCUSSION :

           A 84 year male patient  presented to OPD with C/C of fever since 2 months

           Shortness of breath since 1 month 

            Decreased urine output since 1 month

          

             Pain abdomen  since 2days 

HOPI :

        Patient was apparently asymptomatic 

2 months back then he developed fever which is intermittent type, low grade fever associated with chills,  body pains,  loss of appetite  since 3days.

          H/o dyspnea since 1month..which is insidious in onset aggrevated while walking, doing daily activities and relieved on lying down.No posturnal and diurnal variations 

          Decreased urine output since 1 month.       burning sensation while micturition

          He has h/o  pain abdomen since 2days, which is  diffuse,  cramping type. 

        

            He has no h/o  headache, vomiting, cough, dysuria, diarrhea, constipation, palpitations ,pedal edema .

 

PAST HISTORY:

        No similar complaints in past 

         Known case of  HTN: 7 years  and on medication telma40mg and amlog 5mg

         Know case of CKD : 1year 

          H/o  ORIF  surgery on Right knee 2yrs back 

  

 PERSONAL HISTORY:

          Diet :mixed

          Sleep :adequate  

           Appetite :decreased 

           Bowel: regular

            Addictions: alcoholic,  toddy ocassionally

                                 Smokes beedies 1pack/day.

        Not allergic to  any drugs 

 PHYSICAL EXAMINATION:

          

          Patient is conscious, coherent, cooperative, moderately built. 

           No pallor, icterus, clubbing,cyanosis ,pedaledema,lympadenopathy.

            Vitals: bp-100/80mmhg

                         PR-74bpm

                          RR-24cpm 

                          Temp- 97.1F 

  SYSTEMIC EXAMINATION:

 

             Respiratory system :  trachea central

                                                 Normal   Vesicular breath sounds heard. B/l air entry present.

 Dyspnoea

No wheeze, no added sounds. 

             Per abdomen: 

                      Shape of abdomen: scaphoid 

                       No tenderness present 

                       No organomegaly

                        Bowel sounds heard

             CVS: 

                  S1,S2 heard

                  No murmurs

             CNS:patient is conscious 

                      Speech normal 

                      Cranial nerves intact 

                       Sensory system normal 

                         Motar system normal 

                         No signs of meningeal irritation

  INVESTIGATIONS: 

        Hemogram 

                 

                 

              RFT:

  

CUE: 

 ECG:

USG OF ABDOMEN:

LFT:  

 URINE CULTURE:

 

MALARIA PARASITE STRIP TEST:

ESR:

DIAGNOSIS: 

URINARY TRACT INFECTION  WITH CKD STAGE 4 

TREATMENT: 

Inj.pantop 40mg iv OD

Inj. Zofer 4mg iv SOS

Tab. Ciprofloxacin 500mg BD

Tab. Nodosis 500mg  p/o TID

Inj. Buslopan 2cc im OD

IVF 20 NS at 50 ml/hr 

Inj.thiamine  1 amp in 100 ml NS  OD

Inj. Optineuron 1 amp in 100 ml NS OD

Tab. PCM 650 mg P/o SOP