A 65 years old male patient complaints of

 This online elog book to discuss for patients deidentified health data shared after taking her/guardians signed informed consent

Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs

CHIEF COMPLIANT: A 65 years old male patient came with a chief compliance of 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.

HISTORY OF PRESENT ILLNESSES: 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 4 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- Decrease

ADDICTIONS- Consumes alcohol and smokes occassionally

GENERAL EXAMINATION

patient is concious/coherent/cooperative, moderately built and nourished

No pallor

No icterus

No clubbing

No edema

No lymphadenopathy

Vitals: Temp- 101

            PR- 80 BP

            RR- 19 CP

            BP- 120/70 mm H

            SpO2- 98%@ R

            GRBS- 387 mg/d

Systemic EXAMINATION

CVS: S1 S2 + ,NO MURMUR

RS: BAE+

CNS: INTACT

INVESTIGATION

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