An 80 year old male suffering from fever cold,coug, burning micturation and pedal edema
Hi, I am Kadadasu Srijani of 3rd semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio.
The patient’s consent was taken verbally prior to history taking and examination of his/her condition.
An 80-year-old male came to OPD who is farmer came with
CHIEF COMPLAINTS:
Fever since 10 days
Cold, cough, burning micturation since 7-8 days
Bilateral pedal edema since 5-6 days
Decreased urine output since yesterday
HISTORY OF PAST ILLNESS:
Hypertension since 5 years
Medication:
Tab. Amlodipine 5 mg + Tab. Atenolol 50 mg
Diabetes Mellites since 4 years
Medication:
Tab. Glmepride 1 mg + Tab. Metformin 500 mg
No asthma
No TB
PERSONAL HISTORY:
Married
Lost appetite
Mixed diet
Irregular bowel movement
Abnormal micturation
Addictions:
Alcohol 90 ml occasionally
Smoking beedis since 40 years
No drug usage
FAMILY HISTORY:
No significant family history
GENERAL EXAMINATION:
Bilateral pedal edema : pitting type
VITALS:
BP - 110/70 mm Hg
RR - 22 cpm
REPORTS:
ULTRASOUND:
ECG:
2D ECHO:
TREATMENT:
NF-20NS @75 ml/hr
Inj. Lasix 40 mg/IV/STAT
Inj. Har 6U/IV/STAT
GRBS hourly monitoring
Inj. Piptas 40mg
Inj. Pan 40 mg
Protien-x powder 2-3 scoops
PROVISIONAL DIAGNOSIS:
Altered sensorium secondary to Hyponatremia? Hepatic encephalopathy. True Hyponatremia secondary to Hypovolaemia. Dyselectrolytemia secondary to Acute Kidney Injury (? prerenal)
