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

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