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 rigors2) burning micturition2) c/o nausea and vomitings since 5 days3) c/o giddiness since 5 daysHistory was taked from her attender who is a reliable sourceHISTORY 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 , EPILEPSYNO H/O PAST SURGERIESFAMILY HISTORY:No similar complaints in familyPERSONAL HISTORY:APPETITE : decreased since 10 daysDIET: mixedSLEEP : disturbedBOWEL AND BLADDER : regularMICTURITION : decreasedDRUG 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 painTablet used is unknownShe also took some ayurvedic medicine along the course during same duration along with with painkillers.GENERAL EXAMINATION:She concious coherent and cooperativePallor - presentIcterus - absentCyanosis - absentClubbing- absentGenralised lymphadepathy- absentPedal edema - noneVITALSTEMP : 98.6 ⁰CBP : 140/80 mm hgRR : 20 cpm post extubationPR : 108 bpmSYSTEMIC EXAMINATIONCardiovascular systems1 and s2 heard ,no murmursRespiratory systemCentral position of tracheaBilateral air entry presentVesicular breath soundsNo wheeze,no dyspneaAbdomenScaphoid shapeSlight tendernessNo bowel soundsUsg findings:USG ABDOMEN :FINDINGS :-1) Renal calculi ( 10mm) at right PUJ ( pelvico - ureteric junction )2) Renal calculi (10mm) at mid pole of right kidneyINTERPRETATION : -1) Right renal calculi at PUJ causing hydronephrosis of the same kidney.2) mild hydronephrosis noted in the left kidney.Differential diagnoses:1) acute glomerulonephritis2) acute kidney injury3) infection of the renal caliculi along with hydronephrosisTREATMENT28/11/22Inj. Human actrapid Insulin -- > 10 units29/11/22Lasix ---> 40mg PO BDOrofer---> PO OD × 7 daysShelcal ---> 500 mg PO ODParacetamol ---> 650 mg PO SOSZOFER ---> 4mg IV stat30/11/22Dialysis ( 29/11/22):- during which she experienced a seizure (around 11pm [29th]-12 am[30/11])episode which was controlled byLEVIPIL ---> 1g IV statOPTINEURIN 1g IV statThen she was intubatedGivenInj. ATRACURIUMInj. DEXAMETHASONEInj. LEVIPIL ---> 500mg IV TIDInj. MONOCEF---> 1gm IV BDTab LASIX---> 40 mg PO ODTab OROFER---> PO ODTab SHELCAL---> 500mg PO ODTab paracetamol ---> 650mg PO SOSInj. OPTINEURINInj. PAN ---> 40 mg IV OD
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