Final exam short case

Welcome and greetings to every one who are visiting my blog. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan. 
 
A 65 yrs old female patient came to opd on 11-01-2023 

CHEIF COMPLAINTS:


complain of pain in  abdomen : 2 days

Associated with nausea and vomiting -: 1day


HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 2 years back then she developed pedal edema, facial puffiness, decreased urine output ,short ness of breath and difficulty in moving lower limbs  and was taken to a private hospital and diagnosed to have hypokalemic and found to have raised creatinine levels 
1 year back patient started walking with support and decreased pedal edema and facial puffiness and decreased urine output and diagnosed with CKD (  increased creatinine, shrunken kidney,anemia) 
2months back pain in abdomen, decreased appetite, burning micturition and cloudy urine for 6 days which subsided on use of medication 
2days back pain abdomen - all over diffuse and squeezing type
Vomiting,nausea and pain in abdomen 

PAST HISTORY:

N/K/C/O DM, TB, HTN , EPILEPSY,ASTHMA.
No history of past surgery 
Blood transfusion 2months back 2prbc

FAMILY HISTORY:
No similar complaints in family 

PERSONAL HISTORY: 

Patient is stays near Nalgonda and work as a daily labour /farmer 
Diet- mixed
  APPETITE : decreased 
  BOWEL  : regular
  MICTURITION : decreased 
Sleep- noraml sleep 
Addictions: Alcohol occasionally  (stopped 10 years back) 
 
GENERAL EXAMINATION:

Patient is conscious coherent and cooperative, well oriented to time,place and person.

Thin built and moderately nourished

No Icterus, cyanosis, clubbing , Lymphadenopathy,edema

Pallor-present




Vitals-

Temp:afebrile 

PR: 90 bpmp

BP: 120/70 mmHg

RR: 20 cpm

Systemic Examination:

CARDIOVASCULAR SYSTEM:

Inspection: normal on inspection, apex beat not visible,no visible pulsation ,equal and symmetrical chest movement 

Palpation: all the inspections are confirmed 

Percussion: all the borders of heart normal on percussion 

Auscultation:S1 and  S2 heart sounds are heard

No murmurs heard 

RESPIRATORY SYSTEM:

INSPECTION:

Chest is symmetrical

Trachea:central

No supraclavicular hollowing

PALPATION:


No intercoastal widening or narrowing

Measurement of chest expansion

Whole thorax:35.5cm

Hemi Thorax:17cm

AUSCULTATION:

Vesicular breath sounds

No wheeze 


Percussion-

No fluid thrills and  shifting dullness


ABDOMEN:

INSPECTION:

shape-scaphoid

Flanks-free

Umbilicus-inverted and central position 

No dilated veins 

No scars and sinuses

PALPATION:

Non tender

No Local rise of temperature 

No palpable Mass 

Spleen and liver not palpable 


PERCUSSION :

No fluid thrill 

No shifting dullness 


AUSCULTATION:

Bowel sounds-present 


CNS:

Concious

Speech normal

Gait normal 

Sensory system normal

Motor system normal

Investigation-

Chest X-ray-

ECG-

Ultrasound-


2D Echo-













Provisional Diagnosis:

Acute kidney injury on chronic kidney disease 

Treatment 

T.LASIX 40MG PO/OD
T.SHElcal 500MG PO/OD
CAP.BIO D3 PO/Once weekly
T.Oroferon  PO/OD
Inj.EPO 4000 iu S/C /Once weekly
T.NODOSIS 500MG PO/BD
Syp. MUCAINE GEL PO/BD
T.DOLO 650MG PO/SOS
Inj.MONCEF 1GM /IV/BD




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