65 yr old female with vomitings
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. 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.
CHIEF COMPLAINTS :
Vomitings since 1 week.
Burning micturation and decreased urine output since 1 week.
History is taken from attender(reliable)as patient is weak.
HOPI:
Patient was apparently asymptomatic 20years ago,then she developed shortness of breath every year during winter season and subsided after medication.
Then,she developed neckpain,backache and bilateral knee joint pains since 3-4years for which she is taking ayurvedic medicine and pain killers-1 to 2 tablets per episode.
Then she developed low grade fever which is intermittent, assosiated with chills,rigor and generalised weakness and gradually temporarily relieved on medication.
H/o nausea and vomitings since 1week,which is non-bilious,non projectile,2-3 episodes per day,which made her weak and was taken to local RMP,where she was treated with Saline infusion and Paracetamol and was referred to our hospital for testing where she was diagnosed with Hypertension.
H/o burning micturation and decreased urine output since since 1 week.
PAST HISTORY:
No similar complaints in the past.
She is a known case of hypertension which was diagnosed 1 week back.
Not a known case of Diabetes,TB, Epilepsy.
SURGICAL HISTORY:
She underwent Cataract surgery in right eye 7 years back.
PERSONAL HISTORY:
Diet:Mixed
Appetite: Decreased since 14days
Sleep: Disturbed
Bowel and bladder movements used to regular but decreased since 1 week.Burning micturation present since 1 week.
No addictions.
FAMILY HISTORY:
No relavent family history.
DRUG HISTORY:
History of some unknown medications which helped her in relieving her SOB every winter(anti histamines??)
History of pain killer(unknown) usage for recurrent episodes of neck pain,back pain and knee pains,2-3 tablets per day per episode.
GENERAL PHYSICAL EXAMINATION:
Patient is conscious, coherent, co operative,well oriented to time place and person.She is moderately built and nourished.
No signs of pallor,icterus, cyanosis, clubbing generalised lymphedenopathy and pedal edema.
Vitals:
Temperature:97.4F
Respiratory rate: 16 cpm on post extubation.
B.P:120/80 mmHg.
Pulse rate:82bpm
Systemic examination:
CVS:S1,S2 Heard,no murmurs.
RS: Bilateral air entry present.NVBS Heard.
Per abdomen:Soft,non tender and no organomegaly.Bowel sounds heard.
CNS:Higher motor functions intact
Cranial nerves intact
Power:5/5 in all four limbs
Tone:Normal in all four limbs.
INVESTIGATIONS:
28.11.22
USG:
Interpretation:
Right renal calculi at PUJ causing hydronephrosis of same kidney.
Mild hydronephrosis noted in left kidney.
PROVISIONAL DIAGNOSIS:
Post renal AKI,Secondary to right PUJ calculus,hyperkalemia corrected,
Seizures secondary to uremic encephalopathy.
TREATMENT:
28/11/22
Inj. Human actrapid Insulin -10 units
29/11/22
Lasix - 40mg PO BD
Orofer- PO OD × 7 days
Shelcal - 500 mg PO OD
Paracetamol -650 mg PO SOS
ZOFER - 4mg IV stat
30/11/22,
Central line done.
Dialysis ( 29/11/22):- during which she experienced a seizure (around 11pm [29th]-12 am[30/11])episode which was controlled by
LEVIPIL -1g IV stat
OPTINEURIN 1g IV stat
Then she was intubated
Given
Inj. ATRACURIUM
Inj. DEXAMETHASONE
Inj. LEVIPIL - 500mg IV TID
Inj. MONOCEF- 1gm IV BD
Tab LASIX- 40 mg PO OD
Tab OROFER-PO OD
Tab SHELCAL- 500mg PO OD
Tab PCM- 650mg PO SOS
Inj. OPTINEURIN
Inj. PAN -40 mg IV OD
01/11/22
HD done around 4:30pm
Inj. LEVIPIL - 500mg IV TID
Inj. MONOCEF- 1gm IV BD
Inj. PAN -40 mg IV OD
Inj ZOFER 4ng IV
Tab LASIX-40 mg PO OD
Strict I/O charting
Monitor BP,PR, temperature charting four hourly
2/12/2022,
Inj.LEVIPIL 500mg,iv,bd
Inj.PAN 40mg,iv,od
Inj.MONOCEF 1gm,iv,bd
inj.ZOFER,4gm,iv
Tab.LASIX 40mg,per oral,bd
Inf.NS
Tab.NICARDIA 10mg,po,od
Syrup.ARYSTOZYME 10ml,po,tid
Syrup.ASCORYL 10ml,po,tid
Tab.ULTRACET 1/2 Tab,po,qid
03/12/2022,
DJ stunting done,
Tab.NICARDIA,10ml,po,bd
Inj.LEVIPIL,500mg,po,bd
Tab.LASIX 40mg,po,bd
Tab.MONOCEF 1gm,iv,bd
Syrup.ARYSTOZYME 10ml,po,tid.
04/12/2022,
Tab.LEVIPIL 500gm,po,bd
Inj PAN 40mg,iv,od
Inj.ZOFER,4mg,iv
Tab.LASIX,20mg,po,bd
Tab.NICARDIA,20mg,po,bd
Syrup ASCORIL 15ml,po,tid
Syrup CREMAFFIN,10ml,po
Inj.MAGNEX FORTE,1.5gm,iv,bd
Tab.PARACETAMOL,650mg,po
Monitor vitals 4th hourly.
Comments
Post a Comment