65 Yr old male with DKA with community acquired pneumonia and prerenal AKI

Hello all this is J. Mounika, a nineth semester student.This E Log depicts the patient centered approach to learning

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references
 

A 65 year old male was brought to casualty with

CHIEF COMPLAINTS

Fever since 4 days

Breathlessness since 1 day

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 10 days back when he developed cold and cough with expectoration which is greenish and mucoid. Now the expectoration has decreased. 

Then developed fever 4 days back which is high grade, continuous and not associated with chills and rigor.

Complaints of decreased appetite since 3days

And shortness of breath since 1 day     - grade - II now increased to grade - IV since last night.

H/o nausea but no vomiting 

No H/o decreased urine out put, pedal edema, loose stools

DAILY ROUTINE

He is a shopkeeper by occupation according to the attender his daily routine is as follows 

6 am: takes a cup of tea with sugar 

6:30 am: he opens his shop

If he takes a breakfast it's b/w 7-7:30 am

9 am: takes a cup of tea with sugar

11 am: bathes and goes to his shop again

12:30 pm: he eats his lunch 

6:00 pm: takes a cup of tea with sugar 

7:30 pm: takes his dinner which consist of rice 

9 pm: he sleeps

PAST HISTORY


N/K/C/O DM, HTN, TB, Epilepsy, CVA, CAD

Complaints of pain in bilateral knee joints for which he takes NSAIDS when pain increases.

H/o Surgery for right tibial fracture 5 years back

PERSONAL HISTORY

Diet : Vegetarian

Appetite : Normal before 3 days

Sleep: adequate

Bowel and bladder : regular

Addictions : used to smoke but stopped 5 years back

FAMILY HISTORY

Not significant

GENERAL EXAMINATION

Patient conscious and coherent  co-operative

VITALS

Pulse : 98bpm

RR :  21 cpm 

BP :  90/60 mm Hg

Temp. :  99°F

SpO2 : 96%
 

SYSTEMIC EXAMINATION


CVS : S1, S2 hear, no thrills and murmurs 

Rs : position of trachea - central

BAE +,   NVBS +

decreased breath sounds in infra axillary and mammary area

Dysnea, wheeze, rales and ronchi - absent

Abdomen: scaphoid shaped, soft and diffuse tenderness 

CNS:

Slurred speech 

No neck stiffness

Tone : Normal in both the limbs
 
Power : 4/5 in both the limbs

Reflexes :            Right              Left

      Biceps             ++                   ++

      Triceps           ++                   ++

      Supinator       +                       +

      Knee               ++                    ++

      Ankle             ++                    ++

      Plantar       Flexor            Flexor


Cerebellar examination : normal

INVESTIGATIONS



USG
GBS Charting
On 05/12/2023
On 06/12/2023

Provisional Diagnosis:

Diabetic ketoacidosis with community acquired pneumonia with prerenal AKI.

TREATMENT 

2/12/2023

1) NBM until further orders

2) IV Fluids NS @ 100ml/hr

3) Inj. PIPTAZ 2.5gm IV/TID

4) Inj. LINEZOLID 600mg IV/BD

5) Tab. AZITHROMYCIN 500mg OD

6) Tab. FLUCONAZOLE 150 mg OD

7) Inj. HOMAN ACTRAPID INSULIN infusion @ 6units/hr

8) Inj. PCM 18g IV/SOS ( if temp. >= 101°F)

9) Inj. LASIX 20mg IV/BD ( if SPB >= 110)

10) IV Fluids - FRUSIDEX @ 50ml/hr

11) Tab. ATORUAS 40mg OD

12) Tab. CLOPITAB - A75/75 OD

13) Inj. PAN 40mg IV/OD

14) GRBS moniter hourly
 
15) Moniter BP, PR, RR, SPO2 Hourly

8:40 PM

1) Stop insulin infusion

2) Inj. HAI 6U in 500ml DNS over 5hrs

3) Inj. KCL 20mEq in 500 NS over 5hrs

Followed by 

4) Inj. KCL 20mEq in 500 NS over 5hrs

5) GRBS moniter hourly

3/12/2023

1) Inj. PIPTAZ 2.25gm IV/TID

2) Inj. LINEZOLID 600mg IV/BD

3) Tab. AZITHROMYCIN 500mg OD

4) Tab. FLUCONAZOLE 150 mg OD

5) Inj. PAN 40mg IV/OD

6) Inj. PCM 1g IV/SOS ( if temp. >= 101°F)

7) Inj. LASIX 20mg IV/BD ( if SPB >= 110)

8) Inj. HOMAN ACTRAPID INSULIN infusion  S/L TID according to GRBS

9) Tab. ATORUAS 40mg OD

10) Tab. CLOPITAB - A75/75 OD

11) GRBS moniter 2 hourly

12) Moniter BP, PR, RR, SPO2  2 Hourly

13) Nebulization with IPRAVENT 8th hourly and BUDECORT 12th hourly

14) Inj. KCL 20mEq in 500 NS over 5hrs

15) Tab. FENOFIBRATE 160mg OD

16) Tab. METOPROLOL 25mg OD

17) IV fluid DNS with 6u HAI + 20mEq KCl at 100ml/hr

4/12/23
1) Inj. PIPTAZ 2.25gm IV/TID

2) Inj. LINEZOLID 600mg IV/BD

3) Tab. AZITHROMYCIN 500mg OD

4) Tab. FLUCONAZOLE 150 mg OD

5) Inj. PAN 40mg IV/OD

6) Tab atorvas 20 MG OD

7)tab metaprollel 25 mg oral OD

8) tab fenofibrate 160 MG OD

9) tab sporolac oral OD

 10)Inj.calcium gluconate IV

11)Neb. Budecort inhaler
 
05/12/23

1) Inj. PIPTAZ 2.25gm IV/TID

2) Inj. LINEZOLID 600mg IV/BD

3) Tab. AZITHROMYCIN 500mg OD

4) Tab. FLUCONAZOLE 150 mg OD

5) Inj. PAN 40mg IV/OD

6) Tab atorvas 20 MG OD

7)tab metaprollel 25 mg OD

8) tab fenofibrate 160 MG oral OD

9) tab sporolac oral OD

10)Alkastone syrup

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