55year old male with decreased urine output and pedal edema
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 patients clinical problems with collective current based inputs.
A 55 year old male came to the casuality with cheif complaints of
Cheif complaints:
-decreased urine output since 3days
- pedal edema and Upper limb edema since 3days
- fever since 1day
History of presenting illness:
Patient was apparently asymptomatic 3days ago, later he developed pedal edema, Upper limb edema decreased urine output since 3days. Fever since 1day, low grade not associated with chills and rigors
No c/o burning micturition, vomitings, loose stools, cough, SOB, cold
No c/o rashes, mosquito bites
No c/o generalised body pains or myalgia
Past history:
K/c/o DM since 10yrs
K/c/o HTN since 2yrs
H/o Pulmonary TB 12yrs ago (taken treatment for 6months)
H/o PSVT- Adenosine- S/P RFA 4yrs ago
H/o old CVA- B/L thalamocapsular infarcts 2years ago
Personal history-
Diet- mixed
Appetite - normal
Sleep- Adequate
Bowl and bladder movements- c/o constipation- hard stools, decreased
Habits- drinks alcohol weekly twice
General examination:
Patient is conscious, coherent and cooperative
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
Pedal edema+
Upper limb edema+
Vitals on admission:
Bp- 150/70mmHg
Pulse- 112bpm
RR- 24cpm
Temp- 98
Spo2- 99@RA
Grbs- 55
Systemic examination:
CVS- S1 S2+
RS- BAE+, diffuse wheeze, crepts+ in IAA, ISA, IMA
CNS - NAD
P/A- soft, non tender
Day 1
Abg on admission:
Treatment
Day 1
1. IVF NS@ Urine output 30ml/hr
2.INJ LASIX 40mg IV/BDq
3. INJ PIPTAZ 4.5mg IV STAT
4. INJ HAI s/c
5. Tab Cilnidpine 10mg PO/OD
6. Tab MET XL PO/OD
7. Tab Azithromycin 500mg PO/OD
8. Neb with doulin and budecot
Day 2
1. IVF NS@ Urine output 30ml/hr- stop
2.INJ LASIX 40mg IV/BD
3. INJ PIPTAZ 2.5g IV TID
4. INJ HAI s/c
5. Tab Cilnidpine 10mg PO/OD
6. Tab MET XL PO/OD
7. Tab Azithromycin 500mg PO/OD
8. Neb with doulin and budecot
1st session of HD
Day 3
1. Normal diabetic diet
2.INJ LASIX 40mg IV/BD
3. INJ PIPTAZ 2.5g IV TID
4. INJ HAI s/c
5. Tab Cilnidpine 10mg PO/OD
6. Tab MET XL PO/OD
7. Tab Azithromycin 500mg PO/OD
8. Neb with doulin and budecot
Day 4
1. Normal diabetic diet
2.INJ LASIX 40mg IV/BD
3. INJ PIPTAZ 2.5g IV TID
4. INJ HAI s/c
5. Tab Cilnidpine 10mg PO/OD
6. Tab MET XL PO/OD
7. Tab Azithromycin 500mg PO/OD
8. Neb with doulin and budecot
9. GRBS 2nd hourly
10. Vitals monitoring 2nd hrly
11. Oral fluid < 2L/day
2nd session of HD
Day 5
1. Normal diabetic diet
2.INJ LASIX 40mg IV/BD
3. INJ PIPTAZ 2.5g IV TID
4. INJ HAI s/c
5. Tab Cilnidpine 10mg PO/OD
6. Tab MET XL PO/OD
7. Tab Azithromycin 500mg PO/OD
8. Neb with doulin and budecot
9. GRBS 2nd hourly
10. Vitals monitoring 2nd hrly
11. Oral fluid < 2L/day
Day 6
1. Air bed, frequent change in position
2.INJ PIPTAZ 2.25gm IV TID
3. INJ LEVOFLOXACIN 250mg IV/OD
4. IVF @NS URINE OUTPUT 30ml/hr
5. INJ LASIX 40mg IV/BD (if SBP > 110)
6.INJ HAI s/c acc to grbs
7.Tab Cilnidpine 10mg RT/OD (if SBP >110/80)
8. Tab MET XL 25mg RT/OD (if SBP >110/80)
9.Tab ECOSPRIN AV (75/20) RT/OD
10.Neb with duolin and budecot (4th hrly)
11.Tab Azithromycin 500mg RT/OD
12.RT feeds 200ml milk + 100ml water 4th hrly
13. GRBS 4TH hrly
14. SpO2, BP, PR, monitoring 2nd hrly
Day 7
1. Air bed, frequent change in position
2.INJ PIPTAZ 2.25gm IV TID
3. INJ LEVOFLOXACIN 250mg IV/OD
4. IVF @NS URINE OUTPUT 30ml/hr
5. INJ LASIX 40mg IV/BD (if SBP > 110)
6.INJ HAI s/c acc to grbs
7.Tab Cilnidpine 10mg RT/OD (if SBP >110/80)
8. Tab MET XL 25mg RT/OD (if SBP >110/80)
9.Tab ECOSPRIN AV (75/20) RT/OD
10.Neb with duolin and budecot (4th hrly)
11.Tab Azithromycin 500mg RT/OD
12.RT feeds 200ml milk + 100ml water 4th hrly
13. GRBS 4TH hrly
14. SpO2, BP, PR, monitoring 2nd hrly
Comments
Post a Comment