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)


PERSONAL HISTORY :

Diet : mixed

Appetite : normal

Sleep : normal

Bowel and Bladder : Regular

No allergies

Addictions : Occasional Smoker


FAMILY HISTORY :
Insignificant


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 :











2D ECHO :


USG ABDOMEN :

CHEST XRAY :

ECG :

28/03/23








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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