68 year old male with shortness of breath and anuria

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 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-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.


Complaints: 


68 year male with shortness of Breath since 3 days Anuria since 1 day


History of presenting illness:


Patient was apparently asymptomatic 6 months Back & Then developed SOB with

pain abdomen in Rt. Hypochondrium & was diagnosed to cholelithiasis & managed conservatively.

He was fine till 6 days back then he had Loss of appetite & decreased food and water intake after which he had shortness of Breath since 3 days.


PAST HISTORY:

K/c/o HTN since 6 months and on irregular medication - T.AMLONG 5 mg and T.ATENOLOL 50mg PO/OD

N/k/c/o DM,TB,CVA,CAD,Thyroid disorders,Epilepsy 


PERSONAL HISTORY:

Diet-mixed 

Appetite-normal

Bowel and bladder- anuria since 1 day

Addictions- drinks alcohol daily upto 90ml 


General examination-

Patient is C/C/C

BP-130/80mmhg

PR- 96 bpm

RR- 18cpm

GRBS- 104 mg/dl

Temp- 98.2F


SYSTEMIC EXAMINATION 


CVS- S1S2+,NO MURMURS

RS- BAE+,NVBS HEARD

P/A- SOFT,NON TENDER,BOWEL SOUNDS+

CNS- ORIENTED TO TIME,PLACE AND PERSON


CLINICAL IMAGES and INVESTIGATIONS












DIAGNOSIS


? Septic shock 

? cardiogenic shock with k/c/o HTN since 6 months


TREATMENT


1.IV NS, RL - 75 ml/hr

2.Inj. Noradrenaline 4 mg + 46 ml NS infusion at 5ml/hr increase or decrease to maintain MAP > or equal to 65 mmhg

3. Monitor Vitals hourly

4. Strict I/O and temperature charting


PATIENT LEFT THE HOSPITAL AGAINST MEDICAL ADVICE.

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