Medicine logbook by J.Sasi Harshith

 "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 patient's 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 the comment box

Dt. 06.06.2022

HALL TICKET NO: 1701006065

CHIEF COMPLAINTS:

80 years old male resident of marrigudem, agriculture labourer by occupation came to OPD with the chief complaints of

 i)Fever - since 3 days

ii)Decreased urine output associated with burning micturition since - since 2 days  

History of presenting illness

patient is apparently asymptomatic 3 days back. 

I)He has Fever : 

insidious in onset 

Gradually progressive 

with no diurnal variations 

Relieved on medication

Associated with chills, rigors and generalised body pains. It is not associated with cough, cold, shortness of breathe, night sweats.

II)An episode of vomiting:2 days back

Content:Food

Non bilious and not foul smelling

III)Decreased urine output and burning micturition

Burning micturition experienced at start of the urine and relieved after the urination

Decreased urine output since 2 days

 no hematuria association 

Past history:

He was with similar complaints in the past 10years ago, then he consulted a local doctor and relieved on medication (may be antibiotics). And there is continuation of such episodes then refered to higher hospital and diagnosed with renal problem (AKI) which was treated with dialysis once and given some diuretics as he is suffering from oliguria.

He has a recurrent episodes of fever with burning micturition later also.

He is known case of hypertension since 24years. Not a known case of diabetes, tuberculosis,asthma and epilepsy.

Surgical history

He underwent a nephrectomy surgery 27yrs ago donated to his brother.

Personal history

Appetite - normal

Diet- mixed

Sleep - adequate

Bowel - regular

Bladder - oliguria since 2 days, associated with burning micturition, feeling of incomplete voiding. 

Allergies- none

Addiction- 3 beedi/ day from 27yrs of age

Alcohol- occasionally 

Stopped both alcohol and smoking after the nephrectomy surgery.

General examination:

Patient is conscious, coherent, co operative and well oriented to time, place, and person 

moderately build and nourished.

PALLOR

PALLOR:                          Present

ICTERUS:.                         Absent

CYANOSIS:.                      Absent

CLUBBING:.                     Absent

LYMPHADENOPATHY:  Absent

PEDAL EDEMA:.           Present

There was pedal edema 

Gradually progressive 

Pitting type

Bilateral 

Below knees

No local rise of temperature and tenderness 

Grade 2 

Not relived on rest

Not associated with any cardiac, hepatic, venous and respiratory causes.

Vitals:

Febrile 99.2F

Bp- 150/90 mmHg ( on medication)

Pulse rate - 76 BPM

Systemic examination:

CVS examination

No visible pulsations, scars, engorged veins. 

No rise in JVP

Apex beat is felt at 5 ICS medial to mid clavicular line. 

S1 S2 heard . No murmurs.

Respiratory system examination  

Shape of chest is elliptical, b/l symmetrical.

Trachea is central. 

Expansion of chest is symmetrical

 Bilateral Airway E - position

Per abdomen examination

No visible pulsations and scars swellings.

Soft, non tender, no organo megaley.

Umbilicus is inverted. 

CNS EXAMINATION: 

Conscious 

Speech normal

No signs of meningeal irritation 

Cranial nerves: normal

Sensory system: normal

Motor system: normal

Reflexes: Right.       Left. 

Biceps.       ++.            ++

Triceps.      ++.           ++

Supinator  ++.           ++

Knee.          ++.           ++

Ankle         ++.           ++

Gait: normal

No Abdominal distention 

Investigations:

Hemoglobin - 5.5%

Increased WBC count- 19,900

Urea - 129 mg/dl

Creatinine- 6.3 mg/dl

Urine - pus cells (plenty) - urinary tract inflammation

USG report: 

1)Raised echo genicity of right kidney

2) normal size of kidney

3) mild hydronephrosis

4) not visible left kidney

ECG:

Acute (secondary urosepsis) on chronic kidney disease might be due to recurrent urinary tract infection.

Treatment:

Inj. Piptaz -2.25gm/tid

Tab. Lasix -40ug/po/ bd

Tab. Zofer -4mg/po/ sos

Tab. Dolo -650/ po/ sos

Tab. Pan 40mg /po/ od

Nebi. Duolin and Budecort 6hrly

Syr. Mucaine gel 15ml/po/ bd before meal 15min

Syrup. Cremaffin 15ml/po/ sos.