GENERAL MEDICINE CASE-8
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 a series of inputs available global online community of experts with the aim to solve the patient's clinical problems with the collective current best evidence based inputs. This E-log book also reflects my patient centred online learning portfolio and your valuable inputs in the comments section.
Chief complaints:
A 55 year old female presented to casualty with chief complaint of anuria since a day.
Daily routine of the patient: farmer by occupation for breakfast and lunch takes staple food in meals at 1 pm
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptotic 1 year ago , when her sister died she cried a lot , felt weak and was taken to hospital routine investigations were done and was told she had kidney problem and was referred to kamineni and was admitted for 2 sessions of dialysis was taken for kidney operation was done ,used medication for 3 months and the symptoms were relieved.Patient explains about tingling sensation in abdomen and hands.History of fever since 4 days with chills
HISTORY OF PAST ILLNESS
H/o of NSAID use for 1year
History of pedal edema and facial puffiness 6 months ago .
SOB present on walking grade -4
Hypertension since 1year and is on medication
No H/O TB ,asthma
FAMILY HISTORY:No h/o similar illness in the past
TREATMENT AND DRUG HISTORY: Kidney operation was done (acc.to patient due to inflammation of kidney)
No history of drug allergy
PERSONAL HISTORY
Appetite-normal
Diet- mixed
Sleep- adequate
Micturition- decreased and ceased for a day(relieved of medication) no burning sensation
Bowel movements- normal
GENERAL EXAMINATION
Patient is conscious coherent cooperative on examination
Pallor is present ,no icterus
Cyanosis ,clubbing-not seen
Bilateral Pedal edema - present
Loose stools since few days
No regional lymphadenopathy
History of vomiting- non projectile for 1 day
VITALS
Temp: 100°F
BP -140/90 mmhg
PR -92 BPM
SPO2 -98 %@RA
RR -18 CPM
Systemic examination
CVS - s1 s2 + , no added murmurs
Rs - nvbs+
Abdomen- soft , non tender , no organomegaly , bowel sounds - heard
CNS - no focal neurological deficits present
Provisional diagnosis:
AKI on ? CKD
INVESTIGATIONS -
TREATMENT GIVEN
1.IVF NS AND RL 30 ML /HR URINE OUTPUT +
2.INJ.PANTOP 40 MG/IV/OD
3.INJ.ZOFER 4 MG/IV/BD
4.INJ.LASIX 40 MG/IV/BD
5.TAB.NODOSIS 550 MG/PO/BD
6.TAB.SHELCAL 50P MG/PO
7.TAB OROFER /PO/OD
8.TAB.PCM 680 MG/PO/SOS
9..INJ.NEOMAL 1 GM/IV IF TEMP > 101.1 F
10.MONITOR VITALS hourly
Comments
Post a Comment