27 year old male Pt with shortness of breath, burning mucturition

NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.

Chief complaints :

A patient came to opd  with C/o sob grade 4 since morning , burning mucturition since 3 days. bilateral flank pain since 3days


History of presenting illness:


Patient is apparently asymptomatic 1year ago with similar complaints for which he was admitted in outside hospital where he told to have kidney disease, HTN, DM. Managed conservatively 


Past history:


K/c/o HTN & DM Since 1year

K/c/o renal calculi 3years back


GENERAL EXAMINATION:

patient is conscious, coherent , cooperative.

 

No PICKLE


Vital:

Temperature 90F

PR 113 bpm

RR 18 cpm

Bp 130/100 mmhg 

GFBS 136 mg/dl


CVS :


heart sounds S1S2 heard

No murmurs


Respiratory system

NVBS



Per Abdomen

Nontender, soft


CNS- NAD


INVESTIGATIONS














Diagnosis:

AKI ON CKD


Treatment


Tab. LASIX PO 40mg BD

Tab. MET XL 25 mg po/od

Tab. ATORVAS 25 mg PO HS

Tab. PCM 500mg po/od

Tab. PAN 40 mg PO OD

Tab. NICARDIA 20mg BD

Inj . HAI 8am- 2pm- 8pm


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