67M with AKI ON CKD(SECONDARY TO SEPSIS)? ALCOHOLIC HEPATITIS with THROMBOCYTOPENIA with HYPOALBUMINEMIAWith? Rt LOWER LOBE CONSOLIDATION

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Here we discuss our individual patient's problems through series of inputs from available 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-centered online learning portfolio and your valuable inputs on the comment box is welcome.

Here is a case i have seen
67 Y M patient  who is a rikshaw driver by occupation presented with c/o fever since 3 days .
History of present illness:
Pt was apparently asymptomatic 3days back.Then he had fever which is high grade,intermittent, relieves on medications, associated with
chills and rigors.
Decreased urine output since one day.
 No H/o sob , palpitations,chest pain.No h/o night sweats,weight loss,vomitings, cough,cold,dysuria,loose stools,body pains,headache,rashes,burning micturition.
Past history:
No similar complaints in the past.
No significant past history 
Not a k/c/o DM,HTN,Asthma,epilepsy,TB.
Family history:
No history of DM, HTN CAD, CVA, asthma in the family
Personal history: 
Appetite: normal
Bowels: regular 
Chronic alcoholic 300 ml/day since 40 years
Chronic smoker 18 per day since 40 years.
General examination: patient is conscious, coherent.
Subconjunctival hemorrhage is present
Pallor present ,no icterus,cyanosis,clubbing ,lymphadenopathy,edema 
O/E :
Temp:98.6F, PR: 82 bpm
RR:20 com. ,BP: 100/70mmhg
Spo2: 98% at RA.
Cvs:s1s2 heard
No murmurs
Respiratory system:
Bilateral air entry present
Crepitations + in right inframammary area
Per Abdomen:
Scaphoid abdomen,no tenderness,no palpable mass. Bowel sounds heard. 
Liver and spleen not palpable. 
Cns:NAD
Provisional diagnosis:
AKI ON CKD(SECONDARY TO SEPSIS)
? ALCOHOLIC HEPATITIS with THROMBOCYTOPENIA with HYPOALBUMINEMIA
With? Rt LOWER LOBE CONSOLIDATION.



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