A 65 year old female presented with fever and vomitings

  E LOG GENERAL MEDICINE.

Hi, I am G Sai Karthik, 3rd Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.

• This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.
•  * This is an ongoing case. I am in the process of updating and editing this ELOG as and when required

•                                CASE SHEET.                                            

  Chief complaints

  1) c/o fever since 10 days associated with chills and rigors
  2) burning micturition
  2) c/o nausea and vomitings since 5 days
  3) c/o giddiness since 5 days
  
  
  History was taked from her attender who is a reliable source
  
  
  HISTORY OF HER PRESENTING ILLNESS : 
  Patient was apparently normal 30 years ago then developed multiple recurrent episodes of shortness of breath during the  winter season ,these episodes are  not associated with cough, sputum, and  subside after taking medication
   ( Antihistamine??) . This affects her every year .
      Patient   then she developed  neck pain, back ache and and bilateral knee joint pains  3- 4years ago for which she is taking ayurvedic medicine and pain killers, monthly 15 to 20 times ( 1-2 tablets a day).
   Since the past 1 month she was experiencing generalised weakness and generalised body pains.
  Then she developed low grade fever of intermittent type associated since 10 days along with burning micturition thereafter she developed  nausea and vomiting since 5 days which lead her to become lethargic and weak then she was taken to a local RMP where she was treated with saline infusion and paracetamol then she was referred to a higher centre for testing where she was diagnosed with hypertension and then was referred to our hospital on suspicion of kidney disease.
  
  
  DAILY ROUTINE: patient wakes up at around 6 in the morning and then proceeds to the stables where she feed her cows then she returns home and spend the rest of the day often watching tv and sleeping or taking here of her grandkids. The patient does not have a strenuous home life as most of the household work is taken care by her sons and daughter in law's.
  PAST HISTORY:
  HTN was diagnosed 5 DAYS back and she is on TELMIKIND PO OD.
  N/K/C/O DM, TB , EPILEPSY
  NO H/O PAST SURGERIES
  
  
  FAMILY HISTORY:
  No similar complaints in family 
  
  
  PERSONAL HISTORY: 
    APPETITE : decreased since 10 days
    DIET: mixed 
    SLEEP : disturbed
    BOWEL AND BLADDER : regular
    MICTURITION : decreased 
  
  
  DRUG HISTORY :
   Use of some unknown medication which helped in relieving her shortness of breath which occurs every winter ( Antihistamines??)
  Use of painkillers since 3-4 years taking about 15 to 20 tablets for her neck ache , back ache and b/l knee pain 
   Tablet used is unknown 
  She also took some ayurvedic medicine along the course during same duration along with with painkillers.
  
  
   GENERAL EXAMINATION:
  She concious coherent and cooperative
  Pallor - present 
  Icterus - absent
  Cyanosis - absent
  Clubbing- absent
  Genralised lymphadepathy- absent
  Pedal edema - none
  

  

  

  

  

  
  
  
  
       VITALS 
  TEMP : 98.6 ⁰C
  BP : 140/80 mm hg
  RR : 20 cpm post extubation
  PR : 108 bpm
  
  
  SYSTEMIC EXAMINATION 
  
  
  Cardiovascular system
  
  
  s1 and s2 heard ,no murmurs 
  
  
  Respiratory system
  
  
  Central position of trachea 
  
  
  Bilateral air entry present 
  
  
  Vesicular breath sounds
  
  
  No wheeze,no dyspnea
  
  
  Abdomen
  
  
  Scaphoid shape
  
  
  Slight tenderness 
  
  
  No bowel sounds
  Usg findings: 
  USG ABDOMEN :
  FINDINGS :-  
   1) Renal calculi ( 10mm) at right PUJ ( pelvico - ureteric junction )
   2) Renal calculi (10mm) at mid pole of right kidney
  
  
  INTERPRETATION : -
  1) Right renal calculi at PUJ causing hydronephrosis of the same kidney.
  2) mild hydronephrosis noted in the left kidney.
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  Differential diagnoses:
  
  
  1) acute glomerulonephritis
  2) acute kidney injury
  3) infection of the renal caliculi along with hydronephrosis
  
  
  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
  
  
  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 paracetamol ---> 650mg PO SOS
  Inj. OPTINEURIN
  Inj. PAN ---> 40 mg IV OD