GENERAL MEDICINE CASE DISCUSSION

 FINAL PRACTICAL :SHORT CASE 

This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed 

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:

Patient is examined in a well lit room with adequate exposure, after taking the consent of the patient.
She is conscious, coherent and cooperative, moderately built and nourished.

Pallor is present Grade 2 Pedaledema.


no signs of icterus, cyanosis, clubbing, lymphadenopathy. 

VITALS:  
Temperature:Afebrile
Pulse rate:126 beats/min 
Respiratory rate:22cycles/min 
BP:130/90mm of hg
Spo2 at room air-98% 

SYSTEMIC EXAMINATION: 

 Respiratory system:Normal vesicular breath sounds, bilateral air entry present.
CVS:S1S2 heard,No murmurs 
Per abdomen:soft and no tender ,no organomegaly. 
CNS:Higher mental functions ,cranial nerve, sensory, motor system examinations intact,cerebellar functions normal.

PROVISIONAL DIAGNOSIS:  
CKD ON MULTIPLE HEMODIALYSIS.

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)




Comments

Popular posts from this blog

Medicine case discussion

General Medicine Case Discussion

General medicine case discussion