GENERAL MEDICINE CASE DISCUSSION
FINAL PRACTICAL :SHORT CASE
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I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
K.TEJARSHINI
HALL TICKET No:1701006083
June,08,2022.
CASE DISCUSSION:
A 65Year old female known case of chronic kidney disease (CKD) with multiple hemodialysis (MHD)came to the hospital for dialysis with chief complaints of,
Fever,dysuria,burning micturition.
HISTORY OF PRESENTING ILLNESS:
She was apparently asymptomatic 13 years back, In the year 2011 (7/2/11)she complained of fever ,lower back ache and burning micturition for which they went to hospital and USG was done (small b/l kidneys) with serum creatinine of value 2.0 .
From 2012 to 2018 occasional recurrent UTI.
On 21/05/22 complained of leg swelling, decreased appetite,nausea ,vomiting for which they consult nephrologist Diagnosed CKD +UTI+UROSEPSIS with ANAEMIA where she was on dialysis (done 4 dialysis outside hospitals)+AV FISTULA on 27/05/2022.
In our hospital 2 dialysis were done.
TIME LINE OF EVENTS:
PAST HISTORY:
Known case of CKD since 13years and on medical management.
Known case of osteoarthritis,L5-6/L5-S1 RADICULOPATHY diagnosed on 9/08/22 for which she used NSAIDS for 1year.
Not a known case of HTN,THYROID,CAD, DIABETES,CVA,TB, EPILEPSY.
PERSONAL HISTORY:
Appetite:Decreased
Diet:Mixed (stopped eating red meat past 10 years)
Bowel habits:Regular
Bladder habits: Burning micturition
Sleep:Adequate
No Addictions.
FAMILY HISTORY:
No similar complaints in the family.
GENERAL EXAMINATION:
INVESTIGATIONS:
2/06/2022:
RBS:74mg/dl
7/06/2022:
RFT:
Urea:84mg/dl
Creatinine:4.1mg/dl
Uric acid:4.3mg/dl
Calcium:9.5mg/dl, phosphorus:4.2mg/dl,Sodium:142mEq/L, Potassium:3.6mEq/L,chloride:102mEq/L
8/06/2022:
COMPLETE BLOOD PICTURE (CBP):
Hb:8.9 gm/dl
Total count:6,400 cells/cumm
Neutrophils:75%,Lymphocytes:20%, Eosinophils:1%, Monocytes:4%, Basophils:00,Platelet count:1.20lakhs/cumm.
SMEAR: Normocytic Normochromic Anemia with thrombocytopenia.
ABG:
PH:7.50
PCO2:31.7mmHg,PO2:141mmHg,
HCO3:24.6mmol/L,St.HCO3:26.2mmol/L,
BEB:2.0mmol/L,BEecf:1.6mmol/L,TCO2:51 VOL,
O2 sat:98.8%,O2 Count:12.6vol%.
ECG:
TREATMENT:
7/06/2022 ,9PM:
Inj.LASIX 40mg/Po/BD(if SBP >110mmHg)
TAB.NODOSIS 500mg/Po/BD
TAB.OROFEX-XT/Po/OD
TAB.SHELCAL 500mg/Po/OD
CAP.BIO-D3/Po/OD
Inj.NORADRENALINE-DS@5ml/hr(increase or decrease according to MAP)
8/06/2022:
TAB.LASIX 40mg/Po/BD(ifSBP>110mmHg)
TAB.ECOSPRAN 75mg/Po/OD
Inj.IRON SUCROSE once weekly
Inj.RENOCEL twice weekly
TAB.PAN 40mg/Po/OD
TAB. SHELCAL 500mg/Po/OD
Inj.Noradrenaline- DS 5ml/hr(increase or decrease according to MAP)
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