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I have 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 and treatment plan.
Patient came to the casualty on 17-5-23 with complaints of
1. Decreased urine output since one day
2. Loose stools 7-8 episodes since 1 day
HOPI
Pt was apparently asymptomatic till the previous morning, then she developed loose stools (7-8 episodes till today morning), which are watery in consistency, non blood tinged,non mucopurulent associated with abdominal pain and fever ( low grade not associated with chills and rigor).Now abdominal pain and loose stools subsided.
Patient also has c/o decreased urine output (anuria) since today morning which is previously not associated with dribbling of urine,hesitancy, urgency, burning micturition ,
H/o toddy consumption 2 days ago
Past History:-
K/c/o DM-2 since two years ( on Tab metformin 500mg po/od)
K/c/o HTN since 2 years ( on tab amlodipine 5mg+tab lisinopril 5mg)
K/c/o hypothyroidism since 2 years ( on tab thyronorm 50 mcg)
N/k/c/o cad,cva,epilepsy, tb,asthma
Diagnosed with osteoarthritis 10 years back. Uses medication intermittently. Uses Ayurvedic drugs.
Personal history:-
Diet - vegetarian
Appetite- adequate
Sleep-adequate
Bowel and bladder movements- reduced micturition since today morning ,bowel movements regular
Addictions- occasional toddy drinker
Daily Routine:
Patient wakes up in the morning around 6 am freshens up and does her daily chores. Her grandchildren live with her during the school year so she gets them ready and sends them to school She has breakfast at around 10 am usually consisting of chapati or upma. She then relaxes for some time and waits for her grandchildren to come back at 1 and has lunch with them. Afterwards she passes time by taking a nap and chatting with her neighbours. She then has dinner at 7 and sleeps by 8 pm. The patient's attender says she has been more irregular with meals since the past 2 years after her husband passed away.
General examination:-
Patient is conscious, coherent, cooperative well oriented to time, place and person
Pallor, icterus,cyanosis ,clubbing, lymphadenopathy,bilateral pedal edema absent
Vitals :-
PR-98 bpm
BP-100/60 mmhg
RR-18 cpm
Spo2- 99% @ RA
GRBS-120 mg%
Systemic examination:-
PA:
Inspection:
Round, large with no distention
Umbilicus: Inverted
No visible pulsation,peristalsis, dilated veins and localized swellings.
Palpation:
Soft, non tender
No signs of organomegally
Percussion:
No fluid thrill, shifting dullness absent
Auscultation:
Bowel sounds heard
CVS:
Inspection:
There are no chest wall abnormalities
The position of the trachea is central.
Apical impulse is not observed.
There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses.
Palpation:
Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line
Position of trachea was central
Auscultation:
S1 and S2 were heard
There were no added sounds / murmurs.
RESPIRATORY SYSTEM:
Bilateral air entry is present
Normal vesicular breath sounds are heard.
CNS:
HIGHER MENTAL FUNCTIONS-
Normal
Memory intact
CRANIAL NERVES :Normal
SENSORY EXAMINATION
Normal sensations felt in all dermatomes
MOTOR EXAMINATION
Normal time in all limbs
Power 4/5 bilateral ul and ll
Gait normal
REFLEXES
Normal, brisk reflexes elicited- biceps, triceps,
Knee and ankle reflexes not able to elicit due to b/l osteoarthritis
CEREBELLAR FUNCTION
Normal function
No meningeal signs were elicited
Provisional diagnosis:-
ACUTE KIDNEY INJURY (RENAL) ON ?POST RENAL (! STRICTURE URETHRA) CHRONIC KIDNEY DISEASE ( STAGE 5 ESRD) WITH ? SEPTIC SHOCK WITH OSTEOARTHRITIS
B/ L KNEES
HTN PRESENT, DM PRESENT, HYPOTHYROIDISM PRESENT
Treatment:-
1.Salt restriction < 2g / day
2.Fluid restriction < 2l/ day
3.IVF ns,rl,@ u.o +30 ml/hr
4.Inj noradrenaline 1amp + 46 ml ns @ 5ml/ hr( 18mg/hr) increase/ decrease to maintain MAP >65 mmhg
5.inj Lasix 40 mg/iv/od ( if sbp >100 mmhg after informing icu/ nephritis pg )
6. Inj sodium bicarbonate 25meq + 100 ml ns slowly over 30 min
7.tab thyronorm 50 mcg/po/od/bbf
8.tab nodosis 500mg/po/ bd
9.tab orofer- xt /po/od (1-×-×)
10. Tab shelcal / po/ od (×-1-×)
11. Monitor vitals
12. Strict io charting
13. Inj neomol 1g/iv/ if temp >101 f
15. Tab dolo 650 MG/ po/sos
16. Tepid sponging
17. Inj Piptaz 4.5 gm iv/ Stat ( day 1)
F/b
Inj piptaz 2.25 gm iv/ tid
INVESTIGATIONS
Hb 8.2 gm/dl
TLC 7200
N/L/E/M 77/18/1/4
PCV 25.6
PLT 2.23
SMEAR Microcytic hypochromic
RFT
Urea 121
Creatinine 7.5
Uric acid 10.4
Ca 8.8
P 6.0
Na 136
K 4.0
Cl 102
ABG
ph 7.27
pCO2 18.8
PO2 85.1
HCO3 8.5
Blood Lactate 16
Serum iron 34
BP Charting
17/5/23
8 pm 80/40
9 pm 80/60 NA INFUSION started @ 5ml/hour
11pm 70/40 NA infusion @ 5ml/hour
18/5/23
12am 100/60 NA infusion @ 5ml/hour
2am 80/40 NA infusion @ 4ml/hour
3am 130/70 NA infusion @ 4ml/hour
4am 110/60 NA INFUSION @3ml/hour
5am 110/60 NA INFUSION @3ml/hour
8am 100/60NA INFUSION @3ml/hour
10am 110/70NA INFUSION @3ml/hour
11am 110/70 NA INFUSION @3ml/hour
6 pm 120/80 @3ml/hour
7 pm 130/70 @5ml/hour
8 pm 120/70 @5ml/hour
10 pm 100/50 @5ml/hour
19/5/23
12 am 100/70 @5ml/hour
2 am 100/70 @5ml/hour
4 am 100/70 @5ml/hour
6 am 100/60 @4ml/hour
8 am 120/70 @4ml/hour
10 am 100/60 @4ml/hour
12 pm 120/70 @3 ml/hour
2 pm 110/70 @3 ml/hour
SOAP NOTES
18/5/23
S
stools not passed
no fever spikes
unable to lift her rt hand (1st 30° abduction) since yesterday night after rt IJV catheter placement
O
PT c/c/c
BP 100/60
PR 100
Temp 100. 2
RR 44
SpO2 96
CVS S1S2 heard
R/S BAE + NVBS
P/A SOFT, non tender
CNS - NFND
A
AKI (renal) on ? post renal(?stricture urethra)
CKD(stage 5 ESRD)
with ? septic shock
with osteoarthritis b/l knees
HTN + DM+ HYPOTHYROIDISM
P
1.Salt restriction < 2g / day
2.Fluid restriction < 2l/ day
3.IVF ns,rl,@ u.o +30 ml/hr
4.Inj noradrenaline 1amp + 46 ml ns @ 5ml/ hr( 18mg/hr) increase/ decrease to maintain MAP >65 mmhg
5.inj Lasix 40 mg/iv/od ( if sbp >100 mmhg after informing icu/ nephritis pg )
6. Inj sodium bicarbonate 25meq + 100 ml ns slowly over 30 min
7.tab thyronorm 50 mcg/po/od/bbf
8.tab nodosis 500mg/po/ bd
9.tab orofer- xt /po/od (1-×-×)
10. Tab shelcal / po/ od (×-1-×)
11. Monitor vitals
12. Strict io charting
13. Inj neomol 1g/iv/ if temp >101 f
15. Tab dolo 650 MG/ po/sos
16. Tepid sponging
17. Inj Piptaz 4.5 gm iv/ Stat ( day 1)
F/b
Inj piptaz 2.25 gm iv/ tid
18. Plan for hemodialysis
Neurosurgery referral
19/5/23
S
stools not passed
unable to lift her rt hand (1st 30° abduction) since yesterday night after the insertion of rt IJV catheter placement
O
PT c/c/c
BP 120/70
PR 89
Temp 98
RR 21
SpO2 98
GRBS 138 mg/dl
I/O 2100/1000 ml
CVS S1S2 heard
R/S BAE + NVBS
P/A SOFT, non tender
CNS - NFND
A
AKI (renal) on ? post renal(?stricture urethra)
?2° to ACUTE GASTROENTERITIS ON
CKD(stage 5 ESRD)
with ? septic shock
with osteoarthritis b/l knees
HTN + DM+ HYPOTHYROIDISM
P
1.Salt restriction < 2g / day
2.Fluid restriction < 2l/ day
3.IVF ns,rl,@ u.o +30 ml/hr
4.Inj noradrenaline 1amp + 46 ml ns @ 5ml/ hr( 18mg/hr) increase/ decrease to maintain MAP >65 mmhg
5.inj Lasix 40 mg/iv/od ( if sbp >100 mmhg after informing icu/ nephritis pg )
6.tab thyronorm 50 mcg/po/od/bbf
7.tab nodosis 500mg/po/ bd
8.tab orofer- xt /po/od (1-×-×)
9. Tab shelcal / po/ od (×-1-×)
10. Inj Piptaz 2.25 gm IV/TID(1-1-1)
11. Inj Neomol 1 gm IV/SOS(IF temp >101F)
12. Tab DOLO 650 mg PO/SOS
13. Monitor vitals
14. Strict io charting
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