A 60 year old male patient with ? UTI,CHRONIC CYSTITIS,? AKI ON CKD,Hypokalemia secondary to ? insulin use.

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







A 60 year old male patient came to casualty with c/o high grade fever since 5 days,
Dry cough since 6 days,
SOB on exertion since 4 days.
C/o constipation since 4 days.
C/o burning micturation since 10 days.
No c/o decreased urine output.


HOPI: Patient was apparently asymptomatic 10 days back, then he had burning micturation,and high grade fever a/w nausea and dry cough, not a/w chills and rigor,he had constipation since 5 days.
 
PAST HISTORY: Patient is a k/c/o DM since 30 yrsand was on medication DAPAGLIFLOZIN 10 MG OD and TAB. VOGLIBOSE 0.3 MG OD and  on insulin since 2 days MIXTARD as his Sr.Creatinine is 2 mg/dl
K/C/O HTN since 30 years on TAB. AMLONG 2.5 MG OD .


PERSONAL HISTORY

DIET- MIXED
APPETITE- Normal
SLEEP- Adequate
B&B- Decreased
ADDICTIONS- Consumes alcohol occasionally.

GENERAL EXAMINATION:
patient is concious/coherent/cooperative, moderately built and nourished.

No pallor
No icterus
No clubbing
No edema
No lymphadenopathy.

Vitals: Temp- 101 F
            PR- 80 BPM
            RR- 19 CPM
            BP- 120/70 mm Hg
            SpO2- 98%@ RA
            GRBS- 387 mg/dl

Systemic examination:
CVS: S1 S2 + ,NO MURMURS
RS: BAE+, NVBS
CNS: INTACT
P/A: SOFT, DISTENDED, GUARDING + ,BS SLUGGISH.

INVESTIGATIONS













PLAN OF TREATMENT
KCl one ampoule in 10 ml NS over 4 hrs.
Inj.MONOCEF 1gm IV BD
Inj PANTOP 40 mg IV OD
Inj.ZOFER 4 mg IV SOS
Inj.NEOMOL 1 gm IV SOS
Tab.DOLO 650 mg PO TID
Tab.AMLONG 2.5 mg PO OD
Inj.HUMAN ACTRAPID SC Acc to GRBS
Syp.LACTULOSE 10 ml PO BD
Syp.GRILLINCTUS 10 ml PO BD

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