SRINIJA KARNEKANTI
3rd semester , Roll no : 63
Under the guidance of Dr.Krupa.( Intern)
This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.
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 a diagnosis and treatment plan.
★ Case scenario :
* A 62 year old female patient came to the OPD on 2 July 2021 with chief complaints of :—
- Decreased urine output since 3 months
- Burning micturition since 2 months.
- Neck and lower back pain since 5 days.
- Shortness of breath since 5 days
- Fever since 1 day.
★ HISTORY OF PRESENT ILLNESS :
- Patient complained of decreased urine output and poor stream of urine and burning micturition ( since 2 months ).
- Patient is suffering from lower back pain and neck pain since 5 days
- There is H/O restricted movements and Shortness of breath which of grade -lV.
- No H/O of Orthopnea , PND , pedal edema , chest pain , palpitations.
★ HISTORY OF PAST ILLNESS :
- Patient having fever since 1day which is of low grade , intermittent , retrives on using medication and not associated with chills and rigors.
- K/C/O CKD ( since 2 years Analgesic Nephropathy and on conservative Rx )
- Not a K/C/O DM, TB , HTN , epilepsy , Asthma.
★ TREATMENT HISTORY :
- There is no usage of drugs as of now.
★ PERSONAL HISTORY :
- Married
- Appetite - normal
- A non-vegeterian
- Micturition : burning micturition at the time of admission now normal
- No H/O known allergies
★ FAMILY HISTORY :
- No H/O of DM , HTN , Asthma , TB , heart diseases , stroke , or any other
★ GENERAL EXAMINATION :
- No - pallor / cyanosis / lymphadenopathy / malnutrition / icterus / clubbing / oedema / dehydration.
- Temperature : 103°F
- PR : 90/min
- RR : 28/min
- BP : 130/80 mmHg
- Spo2 : 98% at room air
- GRBS : 110 mg/dl
★ SYSTEMIC EXAMINATION :
-— CVS
. S1 , S2 are heard
— CNS
. No focal neurological defect is seen
— PA
. Soft and tender
— RS
. Bilateral Air Entry is present
★ INVESTIGATIONS :
( 2/7/2021 )
— HEMOGRAM :
* Haemoglobin : 10.2 g/dl
* Total count : 26600 cells/cumm
* Neutrophils : 93%
* Lymphocytes : 04%
* Eosinophils : 01%
* Monocytes : 02%
* Basophils : 00%
* PCV : 29.1 VOL%
* MCV : 84.1 fl
* MCH : 29.5pg
* MCHC : 35.1 %
* RDW - CV : 13.8 %
* RDW-SD : 42.8fl
* RBC : 3.46 millions/cumm
* Platelet count : 1.5 lakhs/cumm
* SMEAR
- RBC : Normocytic Normochromic
- WBC : Neutrophilic leukocytosis
- PLATELETS : Adequate in number and distribution
- HEMOPARASITES : No Hemoparasites seen
- IMPRESSION : Normocytic Normochromic Anemia with Neutrophilic leukocytosis
— CUE
* Colour : pale yellow
* Appearance : clear
* Reaction : Acidic
* Specific gravity : 1.010
* Albumin : ++
* Sugar : Nil
* Bile salts : Nil
* Bile pigments : Nil
* Pus cells : 4-5
* Epithelial cells : 2-3
* Red blood cells : Nil
* Crystals : Nil
* Casts : Nil
* Amorphous deposits : Absent
* Others : Nil
— RBS : 129 mg/dl
— BLOOD UREA : 182 mg/dl
— SERUM CREATININE : 5.5 mg/dl
ECG ( 2/7/2021 )
TPR Graphic Sheet
ULTRASOUND REPORT
( 2/7/2021 )
★ PROVISIONAL DIAGNOSIS :
* Chronic Kidney Disorder
* Urinary tract infection
★ TREATMENT :
- pt is c/c
- BP : 130/80 mmHg
- PR : 89bpm
- CVS : S1,S2 (+)
- RS : B/L AE (+)
- CNS : NFD
- P/A : Soft
— Rx
- Inj PIPTAZ 4.5gm × IV × start
- IVF NS U.O+ 30ml/hr
- Inj PAN 40mg × IV × OD
- Tab ULTRACET 1/2 tab QID
- I/O charting
— 3/7/2021
- AKI ( 2° UROSEPSIS ) on CKD (ANALGESIC NEPHROPATHY ) 2yrs on Rx
- one fever spike 103°F at 8pm a/w chills , neck pain (+) , decreased lower back pain
- O/E
- pt c/c/c
- Temperature : Afebrile
- PR : 80/min
- BP : 110/70 mmHg
- CVS : S1,S2 (+)
- RS : BAE(+)
- P/A : soft
— Rx
- IVF - NS ( 0.9% U.O/ 30ml/hr )
- Inj PANTOP 40mg / IV /OD
- Inj PIPTAZ 2.25mg / IV / BD
- BP/PR/ Temp : charting
- Strict I/O : charting
— 4/7/2021
- AKI ( 2° UROSEPSIS ) on CKD (ANALGESIC NEPHROPATHY )
- O/E
- pt c/c
- BP : 130/90 mmHg
- PR : 92 bpm
- CVS : S1,S2 (+)
- RS : B/L AE (+)
- CNS : NFD
- P/A : soft
—Rx
- IVF - NS 0.9% U.O +30ml/hr
- Inj PAN 40mg × IV × OD
- Inj PIPTAZ 2.25mg / IV / TID
- Tab ULTRACET 1tab×BD
- I/O charting
- BP/PR/ Temp : charting
- Inj LASIX 20 mg IV/BD if SBP >110mmHg
- Tab MYOSPAZ PO/OD
— 5/7/2021
- AKI ( 2° UROSEPSIS ) on CKD (ANALGESIC NEPHROPATHY )
- O/E
- pt c/c
- Temp : 99.7°F
- BP : 170/90 mmHg
- PR : 82 bpm
- CVS : S1,S2 (+)
- RS : B/L AE (+)
- CNS : NFD
- P/A : soft
—Rx
- Inj PAN 40mg × IV × OD
- Inj PIPTAZ 2.25mg / IV / TID
- Tab ULTRACET 1tab×BD
- BP/PR/ Temp : charting 4th hrly
- I/O charting
- Inj LASIX 20 mg IV/BD if SBP > 110mmHg
- Tab MYOSPAZ PO/OD
- IVF - NS 0.9% 2Units NS @ 75ml/hr
— 5/7/2021
— 6/7/2021
S- Neck pain present,Patient’s feeling better wants to go home. Urine output normal, no burning micturition.
O- BP: 160/90 mm Hg
PR - 98 bpm
Temp - 99.7 F
Hb - 10.2—->8.9——>7.8——>8.2
TLC - 26000—>13900—->13,100 ——>11,100 cells/cu mm
Platelets - 1.5—>1.0—>1.0—->1.5 lakh/cu mm
Blood urea - 182—>173—->167—->159 mg/dl
Serum creatinine- 5.6—>5.4—>4.9—>4.2mg/dl
A- UTI (resolved) CKD Stage - 5 (Analgesic Nephropathy) with denovo HTN
P- Plan for discharge.
Rx:
1) Day4- Inj. PIPTAZ 2.25gm IV/TID continue today and tomorrow
2) Tab. ULTRACET 1 tab x BD x 5 days
3) Tab. LASIX 20mg PO/BD x 5days
4) Tab. MYOSPAZ PO/OD x 5 days
5) Tab. Nicardia 20mg PO/BD
Comments
Post a Comment