57yrs old male patient

57yrs old male patient

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 ICU BED -2

 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

Chief complaints:

C/o of constipation since 20 days 

C/o  of fever since 4 to 5 days

History of presenting illness:

 patient came with c/o of constipation since 20 days I was admitted in hospital for three days 

C/o of fever high-grade since 4 to 5 days more during night 

history of hiccups 15 days back admitted in hospital for three days

 no c/o of decreased urine output vomiting headache
 
chief complaints of decreased appetite since 5 to 6 days

History of past illness :

history of giddiness  accident 8/6 starring went to hospital and scan was done

K/c/o hypertension since 1 1/2 year on medication 

Not a k/c/o  diabetes mellitus TB epilepsy CAD asthma

Personal history :

appetite - lost

 diet - mixed

 bowels  - constipation 

micturition - normal 

no known allergies 

addictions :

 alcohol since 27 years stop at one month back 

 smoking since 27 years stop and 15 days back 

Family history : no significant family history

General examination :

no Pallor ,icterus, cyanosis, clubbing ,lymphadenopathy, Edema, Mal nutrition 


Temperature -afebrile

 pulse rate- 64 BPM

BP-110/70mmHg

SPO2-94%

 GRBS- 124mg /dl

Cardiovascular system :

S1 S2 heard 

no cardiac Murmurs

Respirator system :

no dyspnoea 

no wheeze

 trachea position Central 

breath sounds vesicular 

CNS:

No focal and neurological deficits

     Upper limb                               lower limb


                       Rt                    left               Rt            left


Tone     normal       normal      increased increased


Power           5/5                   5/5             5/5              5/5


Reflexes         right                left


Biceps              ++                   ++


Triceps            ++                   ++


Supinator       ++                   ++


Knee                ++                   ++


Ankle   


Plantar         flexion        Flexion



    
Usg:






Chest xray:



X-ray erect abdomen :












Ecg:



Investigations:
















Provisional diagnosis:

Uremic encephalopathy with Alchohol dependence syndrome with AKI with h/o CVA with k/c/o



Rx:


1.Inj.MONOCEF 1gm IV STAT 
2.IV FLUIDS DNS@50 ml /hr
3.INJ.THIAMINE 200mg IV TID in 100 ml NS over 30 mins
4.SYP LACTULOSE 15ml PO BD
5.MONITOR VITALS 

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