57yrs old male patient

 ICU BED -2

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Chief complaints:

C/o of constipation since 20 days 

C/o  of fever since 4 to 5 days

History of presenting illness:

 patient came with c/o of constipation since 20 days I was admitted in hospital for three days 

C/o of fever high-grade since 4 to 5 days more during night 

history of hiccups 15 days back admitted in hospital for three days

 no c/o of decreased urine output vomiting headache

 

chief complaints of decreased appetite since 5 to 6 days

History of past illness :

history of giddiness  accident 8/6 starring went to hospital and scan was done

K/c/o hypertension since 1 1/2 year on medication 

Not a k/c/o  diabetes mellitus TB epilepsy CAD asthma

Personal history :

appetite - lost

 diet - mixed

 bowels  - constipation 

micturition - normal 

no known allergies 

addictions :

 alcohol since 27 years stop at one month back 

 smoking since 27 years stop and 15 days back 

Family history : no significant family history

General examination :

no Pallor ,icterus, cyanosis, clubbing ,lymphadenopathy, Edema, Mal nutrition 

Temperature -afebrile

 pulse rate- 64 BPM

BP-110/70mmHg

SPO2-94%

 GRBS- 124mg /dl

Cardiovascular system :

S1 S2 heard 

no cardiac Murmurs

Respirator system :

no dyspnoea 

no wheeze

 trachea position Central 

breath sounds vesicular 

CNS:

No focal and neurological deficits

     Upper limb                               lower limb

                       Rt                    left               Rt            left

Tone     normal       normal      increased increased

Power           5/5                   5/5             5/5              5/5

Reflexes         right                left

Biceps              ++                   ++

Triceps            ++                   ++

Supinator       ++                   ++

Knee                ++                   ++

Ankle   

Plantar         flexion        Flexion

    

Usg:

Chest xray:

X-ray erect abdomen :

Ecg:

Investigations:

Provisional diagnosis:

Uremic encephalopathy with Alchohol dependence syndrome with AKI with h/o CVA with k/c/o

Rx:

1.Inj.MONOCEF 1gm IV STAT 

2.IV FLUIDS DNS@50 ml /hr

3.INJ.THIAMINE 200mg IV TID in 100 ml NS over 30 mins

4.SYP LACTULOSE 15ml PO BD

5.MONITOR VITALS