final short case


18 th January 2023

65 years old female patient who is from nalgonda labourer by occupation presented to OPD on 12-01-23

CHEIF COMPLAINTS:

Abdominal pain since 2days 
Associated with nausea and vomiting since 1day

HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 2 years back then she developed pedal edema, facial puffiness, decreased urine output short ness of breath grade 1 and difficulty in moving lower limbs 2 years back and was taken to a private hospital and diagnosed to have hypokalemic (k+2.2) and found to have raised creatinine levels 
1 year back patient started walking with support and decreased pedal edema and facial puffiness and decreased urine output and diagnosed with CKD (  increased creatinine, shrunken kidney,anemia) 
2months back pain abdomen, decreased appetite, burning micturition and cloudy urine for 6 days subsided on medication. 
2days back pain abdomen - squeezing type not associated with loose stools 
Vomiting,nausea and pain abdomen Non bilious ,non projectile, 2 episodes, food particles as content.

PAST HISTORY:

N/K/C/O DM, TB, HTN , EPILEPSY,ASTHMA.
No history of past surgery 
Blood transfusion 2months back 2prbc

FAMILY HISTORY:
No similar complaints in family 

PERSONAL HISTORY: 
DIET :mixed
  APPETITE : decreased 
SLEEP : decreased
  BOWEL AND BLADDER : regular
  MICTURITION : decreased 
Addictions: Alcohol occasionally (stopped 10 years back)

GENERAL EXAMINATION:

Patient is conscious coherent and cooperative, well oriented to time,place and person.

Thin built and moderately nourished

No Icterus, cyanosis, clubbing , Lymphadenopathy.

l
Vitals

Temp:afebrile 

PR: 90 bpmp

BP: 120/70 mmHg

RR: 20 cpm

Systemic Examination:CARDIOVASCULAR SYSTEM:No Thrills, S1,S2 sounds hears,No murmurs. 

RESPIRATORY SYSTEM:

INSPECTION:

Chest is symmetrical

Trachea:central

No supraclavicular hollowing


PALPATION:

Trachea:central

No intercoastal widening or narrowing

Chest movement: symmetrical

Measurement of chest expansion

Whole thorax:35.5cm

Hemi Thorax:17cm

AUSCULTATION:

Vesicular breath sounds

No wheeze 


ABDOMEN:

INSPECTION:

shape-scaphoid

Flanks-free

Umbilicus-inverted and central position 

No dilated veins 

No scars and sinuses 


PALPATION:

Non tender

No Local rise of temperature 

No palpable Mass 

Spleen and liver not palpable 


PERCUSSION :

No fluid thrill 

No shifting dullness 


AUSCULTATION:

Bowel sounds-present 


CNS:

Concious

Speech normal

Gait normal 

Sensory system normal

Motor system normal

 ORAL CAVITY EXAMINATION

patient doesn't have tooth




Provisional Diagnosis:

Acute kidney injury on chronic kidney disease 

Treatment 

T.LASIX 40MG PO/OD
T.SHERCEF 500MG PO/OD
CAP.BIO N PO/Once weekly
T.OPOFER ×T PO/OD
Inj.EPO 4000 iu S/C /Once weekly
T.NODOSIS 500MG PO/BD
syp.CITRALKA 15ML PO/HS
Syp. MUCALINEGEL PO/BD
T.DOLO 650MG PO/SOS
Inj.MONCEF 1GM /IV/BD






Comments

Post a Comment

Popular posts from this blog

A45 year old male patients came to causality with chief complaint of fever , abdomen pain , vomiting and lose stool

Image
CHIEF COMPLAINTS :    A 45 yr old male c/o fever since 5 days, abdominal pain , loose stools and vomitings since yesterday. HOPI: patient was apparently asymptomatic 5 days ago and then developed fever, which is low grade, not associated with chills and rigors and relieved on medication. He complains of diffuse pain abdomen since 11th October morning. He had 3-4 episodes of vomiting on the same day evening, food particles as content and non- bilious in nature .He had loose stools since evening the same day, which is of 5 -6 episodes and so he went to local hospital. He developed weakness of both upper and lower limbs and found to be having low potassium, correction was done and the weakness got improved. He now came with c/o abdominal pain , vomiting and loose stools. PAST HISTORY Not a k/c/o DM, Hypertension, Asthma, epilepsy, CAD, CKD.  He went for a General checkup 6yrs ago, where he was diagnosed as HIV positive. He was on ART .  He met with an accident 3yrs ago and got Right ankle
Read more

A 45 year male patients came to causality with chief complaint of yellowish discoloration of sclera

Image
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. I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. A 40 year old male who is a coconut vender came to casualty with c/o : • constipation since 10 days • Yellowish discoloration of sclera and urine from 3 days. • cough(dry cough) since 2 days. • throat pain sinc
Read more

A65 year old female patients came to causality with chief complaint of stomach while taking food

Image
This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 patient's clinical problems with collective current best evidence based inputs.  CHEIF COMPLAINT   : A 65yr old female patient  complaints of stomach  pain on taking food since 1month HISTORY  OF PRESENT ILLNESS  : A 65yr old female patient  who is aaganwadi worker by occupation was apparently  asymptomatic  1month ago then she noticed stomach pain  on taking food and relived on vomiting  and medication.  HISTORY OF PAST ILLNESS  : H /o hypertension since 20 yrs ( on medication ) No h/o asthma ,diabetes ,epilepsy, thyroid   H/o similar complaint 5yrs back FAMILY HISTORY  :  no relevant family history  PERSONAL HISTORY  :  Married  Diet : mixed Appetite : decreased  Sleep: adequate  Bowe
Read more