Case history-prefinal
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 available global online community of experts with an aim to solve those patients 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 comment box is welcome.
21 December 2021
A 55 year old female presented to casualty with chief complaint of decreased urine output since 15 days and fever from 4 days associated with chills and vomiting(1 episode).
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 year ago. When her sister died, she was crying felt weak and was taken to hospital and routine investigations were done. She was told she had kidney problem and was referred to Kamineni I/V/O dialysis and was admitted, 2 sessions of dialysis were done, symptoms relieved and used medication for 3 -4 months.
6 months back, she had history of Pedal edema and was brought to Kamineni and weekly twice sessions of dialysis were done for 2 months and was told she has kidney stones and curation of dialysis for almost 3-4 months and was on conservative management.
PATIENT DAILY ROUTINE BEFORE ILLNESS:
She used to wake up around 5:30-6:00AM in the morning. After having breakfast,she used to go to the farming. She used to have lunch with rice in the field and returns home at 6:00PM in the evening. She used to have dinner at 9:00PM and sleep by 10:00PM. Patient used to eat 3 times a day with no intermittent snacks and all the three times she used to have rice with the curry or curd or dal.
PATIENT DAILY ROUTINE AFTER ILLNESS:
Patient do not complain of any alterations in the routine except she hasn't been going to the farming since the illness.
HISTORY OF PAST ILLNESS:
H/O hypertension since 1 year and is on regular medication.
No history of DM
No history of Hematuria
No history of TB
No history of Asthma
PERSONAL HISTORY:
Appetite is normal
Mixed diet
Sleep is adequate
Regular bowel movements
Micturation - abnormal - decreased urine output
No allergies
No habits and addictions
FAMILY HISTORY:
No relevant family history
GENERAL PHYSICAL EXAMINATION:
Patient is conscious, coherent and co-operative
Mild pallor is present
No icterus,cyanosis and clubbing
B/L Pedal edema is present
VITALS:
Temp : 100°F
PR : 92/min
RR : 18/min
BP : 140/90 mm/Hg
SPO2 : 98%
SYSTEMIC EXAMINATION:
CARDIO VASCULAR SYSTEM:
No thrills
Cardiac sounds S1 and S2 heard
No cardiac murmurs
RESPIRATORY SYSTEM:
No dyspnoea
No wheezing
Position of trachea - Central
Breath sounds - Vesicular
ABDOMEN:
Shape of abdomen - Scaphoid
No tenderness
No palpable mass
No bruits and free fluid
Liver - Not palpable
Spleen - Not palpable
Bowel sounds - Present
CNS:
No abnormality detected
INVESTIGATIONS:
HEMOGRAM:
On 09/12/21
On 12/12/21
BLOOD GROUPING AND RH :
HBsAg
HCV
RFT
On 11/12/21
On 14/12/21
LFT
On 09/12/21
ABG
URIC ACID SERUM
SERUM IRON
On 13/12/21
On 11/12/21
SERUM ELECTROLYTES
PHOSPHOROUS
BLOOD SUGAR - RANDOM
ECG
ULTRA SOUND REPORT
2D ECHO
PROVISIONAL DIAGNOSIS:
AKI
TREATMENT:
1.IVF - NS - Urine Output + 30ml/hr
RL
2.Inj. Pantop 40mg IV OD
3.Inj. Zofer 4mg IV BD
4.Inj. Lasix 40mg IV BD
5.Tab. Nodosis 550mg PO BD
6.Tab. Shelcal 500mg PO OD
7.Tab. Orofer XT PO OD
8.Tab. PCM 650 mg SOS
9.Inj. Neomol 1gm IV SOS
10.Strict I/O charting
11.Monitor vitals hourly (BP, PR, RR, SPO2)
Comments
Post a Comment