55yr old female with Acute kidney injury
Ankitha
Rollno : 78
This is 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 .
I’ve 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 .
Cheif Complaints :
Patient came to casualty with chief complaints of pain in the left side of face since 3days
Vomitings since 1 day
HOPI :
Patient was apparently alright 3 days back she then developed Pain in tooth on left side of jaw and swelling extending onto the eyelids and to below the ear.
- C/O vomitings since 1 day : 6-7 episodes yesterday which is non-projectile, non bilious , watery in nature with food particles as content ,non blood tinged.
- C/O fever since 1 day high grade, no chills and rigors, relieved by medication.
- Pt has C/O B/L Knee pain , Rt. shoulder pain since 12 yrs and patient gives H/O NSAIDs abuse
- No H/O pain abdomen, chest pain , SOB, palpitations, burning micturition , headache.
PAST HISTORY :
Not a k/c/o DM/TB/HTN/ Asthma / Epilepsy/ CVA /CAD/ Thyroid disease.
H/O ? Ear surgery (2007)
Diet : mixed
Appetite : normal
Sleep : normal
Bowel and Bladder : Regular
No allergies
Addictions : Occasional Smoker
GENERAL EXAMINATION :
Patient is conscious , coherent , cooperative
Moderately built and nourished .
No signs of pallor , icterus , cyanosis , clubbing , lymphadenopathy
Pedal edema present upto ankle
VITALS :
Afebrile.
PR - 98bpm
BP - 100/60 mmhg
RR - 22cpm
SpO2 - 98% on Room air
GRBS - 163mg%
SYSTEMIC EXAMINATION :
CARDIOVASCULAR SYSTEM :
Inspection:
Shape of chest is elliptical.
No raised JVP
No visible pulsations, scars , sinuses , engorged veins.
Palpation :
Apex beat - felt at left 5th intercostal space
No thrills and parasternal heaves
Auscultation :
S1 and S2 heard.
RESPIRATORY SYSTEM:
Inspection:
Shape- elliptical
B/L symmetrical
Both sides moving equally with respiration .
No scars, sinuses, engorged veins, pulsations
Palpation:
Trachea - central
Expansion of chest is symmetrical.
Vocal fremitus - normal
Percussion: resonant bilaterally
Auscultation:
bilateral air entry present
PER ABDOMEN :
Inspection :
Abdomen is obese
Umbilicus is central
All quadrants are moving equally with respiration
No sinuses , engorged veins, visible pulsations .
Hernial orifices are free.
Palpation :
No local rise of temperature
No Tenderness
Liver and Spleen - Not palpable
Percussion : Tympanic note heard over the abdomen.
Auscultation :
Bowel sounds are heard.
CENTRAL NERVOUS SYSTEM:
Conscious,coherent and cooperative
Speech- normal
No signs of meningeal irritation.
Cranial nerves- intact
Sensory system- normal
Motor system:
Tone- normal
Power- bilaterally 5/5
Reflexes Right Left
Biceps ++ ++
Triceps. ++. ++
Supinator ++ ++
Knee. ++. ++
Ankle ++. ++
INVESTIGATIONS :
PROVISIONAL DIAGNOSIS :
Acute Kidney Injury (?PreRenal ) secondary to Sepsis with interproximal caries with osteoarthritis of knee and hip joints
TREATMENT :
1. IVF 1 unit NS 1unit RL @ 75ml/hr
2. Inj. Monocef IV/BD
3. Inj NEOMOL IV / SOS (ifTemp >101F)
4. Inj. ZOFER 4gm IV/SOS
5. Tab.DOLO 650mg PO/TID
6. Inj. Metrogyl 100ml IV/TID
7. Inj TRAMADOL 100 mg IV/SOS
8. Syp. POTCHLOR 10ml Po/BD
9. Inj. Pantop 40mg IV/OD
10. Tab. Chymerol Forte PO/BD
8. Monitor vitals BP,PR, Temp,GRBS 2nd hrly
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