58 yr old female with Acute kidney injury
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I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis .
Chief complaint:
Patient came to casualty with chief complaints of
-pain in the left side of face since 3days
-Vomitings since 1 day
History of presenting illness:
Patient was apparently asymptomatic 3 days back then she developed Pain in tooth on left side of jaw and swelling extending onto the eyelids and to below the ear.
Later she started vomitings since 1 day : 6-7 episodes yesterday which is non-projectile, non bilious , watery in nature with food particles as content ,non blood tinged.
Then fever since 1 day high grade, not associated with chills and rigors, relieved by medication
Patient has B/L Knee pain , Right shoulder pain since 12 yrs and patient gives H/O NSAIDs abuse
No H/O pain abdomen, chest pain , palpitations, burning micturition , headache, shortness of breath
Past history -
No similar complaints in past
Not a known case of hypertension, diabetes, epilepsy, asthma , tuberculosis, thyroid diseases
Personal history:
Mixed diet
Adequate sleep
Appetite- normal
Regular bowel and bladder movements
No allergies
Addictions - occasionally smokes
Family history :
No significant family history
General examination-
Patient is conscious , coherent , cooperative
Moderately built and nourished
No h/o of pallor , icterus , cyanosis , clubbing , lymphadenopathy
B/l pedal edema is present , extended Upto ankle
Vitals ;
Temperature - afebrile
Pr - 90bpm
Bp - 110/60 mm hg
Rr - 20 cpm
Systemic examination -
Cardiovascular system -
Inspection:
Shape of chest is elliptical.
No raised JVP
No visible pulsations, scars , sinuses , engorged veins.
Palpation :
Apex beat - felt at left 5th intercostal space
No thrills and parasternal heaves
Auscultation :
S1 and S2 heard.
RESPIRATORY SYSTEM:
Inspection:
Shape- elliptical
B/L symmetrical
Both sides moving equally with respiration .
No scars, sinuses, engorged veins, pulsations
Palpation:
Trachea - central
Expansion of chest is symmetrical.
Vocal fremitus - normal
Percussion:
resonant bilaterally
Auscultation:
bilateral air entry present
Per abdomen :
Inspection :
Abdomen is obese
Umbilicus is central
All quadrants are moving equally with respiration
No sinuses , engorged veins, visible pulsations .
Hernial orifices are free.
Palpation :
No local rise of temperature
No Tenderness
Liver and Spleen - Not palpable
Percussion :
Tympanic note heard over the abdomen.
Auscultation :
Bowel sounds are heard.
Central nervous system -
Conscious,coherent and cooperative
Speech- normal
No signs of meningeal irritation.
Cranial nerves- intact
Sensory system- normal
Motor system:
Tone- normal
Power- bilaterally 5/5
Reflexes Right Left
Biceps ++ ++
Triceps. ++. ++
Supinator ++ ++
Knee. ++. ++
Ankle ++. ++
Acute Kidney Injury secondary to Sepsis with interproximal caries with osteoarthritis of knee and hip joints
Investigations -
Treatment -
1. IVF 1 unit NS 1unit RL @ 75ml/hr
2. Inj. Monocef IV/BD
3. Inj NEOMOL IV / SOS (ifTemp >101F)
4. Inj. ZOFER 4gm IV/SOS
5. Tab.DOLO 650mg PO/TID
6. Inj. Metrogyl 100ml IV/TID
7. Inj TRAMADOL 100 mg IV/SOS
8. Syp. POTCHLOR 10ml Po/BD
9. Inj. Pantop 40mg IV/OD
10. Tab. Chymerol Forte PO/BD
8. Monitor vitals BP,PR, Temp,GRBS 2nd hrly
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