A 67 year old man presented with SOB and Fever

 Hi, I am princy rose , 5 th sem medical student.This is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.



June 5,2023

Case scenario.......





CASE SHEET:

A 67 year old male barber by occupation,resident of miryalaguda came to the opd with chief complaints of 

Shortness of breath since 1 week 

Fever since 4-5 days

HOPI :

Pateint was asymptomatic 1 week back then he developed shortness of breath grade 2-4 aggrevating on doing work, walking and temporarily relived on medication and fever for which he went to local hospital and they gave medication but symptoms are not relieved and then they went to miryalaguda hospital for checkup and they referred to our hospital.

He also had fever since 4days high grade evening raise temperature associated with chills and rigors relieved by medication and increases again.

H/O decreased urine output since 6 months

C/o pain abdomen on &off left lumbar region since one week

C/o Vomitings 2 days back 2-3 episodes, watery,non-projectile , non-biliary with food particles as contents

C/o low stools 2-3 episodes 2 days back relieved now , watery , non-mucoid , non blood stained , no foul smelling

C/o decrease in appetite since 1 week 

No c/o of chest pain , palpitations 

PAST HISTORY

He had history of hypertension since 10 years and on medication 

TAB Olmesartan -H

No history of diabetes, thyroid,epilepsy,asthma,CAD ,CVA 

History of previous surgery Renal stunting 6 months back



PERSONAL HISTORY: 



Diet:mixed

Sleep:regular 

Appetite: decreased appetite since 1 month 

Bladder - decreased urine output with burning micturation since 1 month

Bowel movements are regular 

Addictions:he started taking chewable tobacco since 30 years and stopped one week back

He also had a history of taking alcohol since 25 years and stopped one year back



Family history: Not significant



Treatment history: 

Renal Stenting 6 months back



General examination::

Patient is conscious,cohorent , cooperative well known with time, place, person 

He is well built and moderately nourish

Pallor present 

Icterus: Absent 

Cyanosis: Absent 

Clubbing: Absent 

Lymphadenopathy: absent 



VITALS:

TEMP:97.2F

PR:117bpm

RR:28cpm

BP:120/80

Spo2: 94% @4L 02

GRBS:128mg/dl







Provisional Daignosis: left hydroneprosis secondary to ? left ureteric obstruction ? Post renal AKI




Treatment:

1.INJ LASIX 40 MG IV STAT

2.NEB WITH DUOLIN STAT BUDECORT

3.INJ NEOMOL 1GM IV SOS

4.TAB DOLO 650MG PO/BD

5.TAB OLMESARTAN-H PO/BD

6.BP,PR,TEMP CHARTING 4TH HOURLY.













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