a case of 70 yr old male


This is 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 patients 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 comment box is welcome.

A 70 yr old male,  resident of miryalaguda, came with chief complaints of
Pain abdomen and burning micrurition since 4 
days
HOPI
Pt. Was apparently asymptomatic 4-5 days ago then developed abdominal distension which was insidious in onset along with burning micrurition. He also noticed blood after retching since 4 days and complained of hiccups since 5 days
Be also suffered from dysphagia since 5 days, unable to swallow both solids and liquids. along with generalized body weakness.



Past history 

Past drug history
Used  tab.gabapentin
Tab. Montelukast
Also used tab. Nortriptyline and tab. Escitalopram  due to lack of sleep.
Does not consume alcohol, sugar and tobacco 

He's not a known case of HTN CAD DM TB but is a known asthmatic since the past 17 years for which he takes beclomethasone with rotahaler.

On admission.
Patient is conscious coherent cooperative 
BP: 120/80mmhg
PR:82
RR: 19 cpm
Temp: afebrile 
CVS:S1 S2+
RS: BAE+
CNS: NAD

REFLEXES-
                        RT. LFT
BICEPS-.        ++. ++
TRICEPS-.      ++. ++
SUPINATOR-.      ++ ++
ANKLE. -.            ++. ++
KNEE-.                ++ ++
P/A:soft, no guarding
No rigidity
 Mild Tenderness felt at left hypochondrium

Grbs: 68mg/dl
No pallor, icterus, cyanosis, clubbing, and lymphadenopathy 

Appetite:normal
Diet:mixed
Bowel and bladder:regular 
Sleep: adequate 
No significant family history

 Investigations

USG



 Provisional Diagnosis:
Pyrexia under evaluation with thrombocytopenia
 AKI on CKD

Treatment
Oral fluids 1.5 liter
Tab. Pan 40 mg PO/OD
Input/ output charting
Inj. Lasix 40mg IV BD
IVF 1 NS



2d echo
12/9/22

Ent refferal


SOAP notes 

70 yr old male, AMC bed 3
S:
Burning micturition 
Unable to swallow food (pain while swallowing)
Headache since yesterday 

O:
Vitals
Bp: 120/90
PR: 96
RR: 20
Temp: 100.6
GRBS: 130mg/dl
Cvs: S1 S2 +
RS- BAE+
P/A- soft
CNS- NAD

A:
Pyrexia under evaluation AKI on CKD with thrombocytopenia 

P:
Tab PAN 40mg PO OD
INJ Lasix 40mg BD IV
IVF @UO+ 30ML/HR
TAB DOLO 650mg SOS
Tab nodosis 550mg PO BD
Syrup cremaffin 15ml PO TID
 

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