65 year old female with decreased urine output since 4 days
This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.
This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed.
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 to come up with a diagnosis and treatment plan.
A 65 year old female, resident of Tondavayi, came to the casualty with chief complaints of decreased urine output since 4 days.
History of presenting illness -
Patient was asymptomatic 1 year back, later she developed itching on the back of her right ankle, which on further scratching developed into small blisters. She then applied mehendi leaves on the blisters which caused the wound to increase in size, associated with pain and redness. She visited an RMP, who gave her analgesics and injection and daily dressing was done.
She also complained of decreased urine output since 8/10/22, for which she visited an RMP and was given tablets, which had no effect on her urine output.
Then she visited Priyanka hospital in Nalgonda, where tests were done and a kidney problem was diagnosed. She was then referred to a government hospital in Gollagudam, and due to lack of dialysis equipment, she was again referred to KIMS.
Patient was admitted on 11/10/22, 7 am in KIMS and a dialysis was planned.
Past history -
No similar complaints in the past.
She is not a known case of hypertension, diabetes, thyroid, epilepsy, cardiovascular abnormalities.
Surgical history -
She underwent a surgery one year back for her left thigh.
Treatment history -
Patient has a history of NSAID intake for pain after her hip surgery.
Personal history -
Mixed diet
Decreased appetite since wound increased in size
Adequate sleep
Regular bowel movement
Bladder movement decreased since 4 days
No addictions
General examination -
Patient is conscious, coherent and cooperative, and well oriented to time, place and person. She is ill-built and malnourished.
Parotid gland enlargement is seen.
Pallor - present
No signs of icterus, cyanosis, clubbing, lymphadenopathy, and edema.
Vitals -
Temperature - Afebrile
Pulse - 82 bpm
Blood pressure - 160/110 mmHg
Respiratory rate - 13 cpm
SpO2 - 98%
GRBS - 90 mg/dl
Local Examination of ulcer -
On inspection -
A ulcer of about 5×4cms, over posterior aspect of ankle, spherical in shape, sloping edges and base is pale.No bleeding and discharge seen.
No other ulcers present.
On Palpation -
No local rise of temperature, no tenderness.
All inspectory findings are confirmed on palpation.
Floor consists of soft tissue.
Pulses present.
No lymphnode palpable.
Provisional diagnosis -
Traumatic ulcer over ankle.
Treatment -
Regular dressing with left limb elevated.
Tab.CHYMORAL FORTE - TID
Tab.TAXIM 200mg per oral, BD.
Tab.METROGYL 500mg per oral, TID.
Systemic examination -
CVS - S1,S2 heard,no murmurs heard
RS - Bilateral air entry present, NVBS heard.
On inspection:
Chest wall-symmetric
Trachea-midline
No drooping of shoulders and no supraclavicular and infraclavicular hollowing.
No winging of scapula.
No sinuses,scars and dilated viens.
On percussion:
Resonant note heard and liver dullness heard on right 4th ICS.
On auscultation:
NVBS heard.
Per abdomen -
On Inspection:
Shape of the abdomen : Slightly distended
Flanks : Free
Umbilicus shape : slit
Skin over abdomen - normal, no sinus, no scars.
No visible peristalsis.
No hernial orifices.
On palpation :
Local rise of temperature, no tenderness.
All inspectory findings are confirmed by palpation.
Liver is palpable, non tender
Spleen is non palpable and non tender.
On percussion :
Fluid thrill and shifting dullness is not present.
On auscultation :
Bowel sounds are heard.
CNS - No focal neurological deficits.
Investigations -
On 11/10/22
On 12/10/22
14/10/22
15/10/22
Provisional diagnosis -
Acute glomerular nephritis secondary to NSAID use
Treatment -
Tab.TAXIM - 200mg, per oral, BD.
Tab.METROGYL - 500mg, per oral, TID.
Tab.CHYMEROL FORTE, per oral, TID.
Comments
Post a Comment