A 65 year old female with fever, vomitings and hypertension which is recently diagnosed.

December 1,2022

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

CHIEF COMPLAINTS :

1) c/o fever since 11 days associated with chills and rigors

2) burning micturition

2) c/o nausea and vomitings since 6 days

History is taken from the attender(reliable) as patient is very weak and couldn't tell.

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 every year and  they subsided after taking medication.

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 1 month she was experiencing generalised weakness and generalised body pains.

Then she developed low grade fever which is intermittent since 11 days along with burning micturition thereafter she developed  nausea and vomiting since 6 days which made her 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 does her household chores then she drinks tea and spends the rest of the day often watching tv and sleeping . The patient does not have a strenuous home life as everything is taken care by her family members.

PAST HISTORY:

HTN was diagnosed 5 DAYS back and she is on TELMIKIND PO OD.

K/C/O DM

N/K/C/O  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

.        Pallor is present 

.        Pedal edema is absent

VITALS 

TEMP : 98.6 ⁰C

BP : 170/90 mm hg

RR : 20 cpm post extubation

PR : 82 bpm

SYSTEMIC EXAMINATION 

Cardiovascular system: 

s1 and s2 heard ,no murmurs 

Respiratory system:

Central position of trachea 

Bilateral air entry present 

Normal vesicular breath sounds heard

Abdomen:

Soft and non tender

No organomegaly

Bowel sounds heard

INVESTIGATIONS

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 DIAGNOSIS:

Acute kidney injury?

Infection of renal calculi 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

(around12am[30/11])episode which was controlled by

    LEVIPIL ---> 1g IV stat

    OPTINEURIN 1g IV stat

Then she was intubated and 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 PCM---> 650mg PO SOS

Inj. OPTINEURIN

Inj. PAN ---> 40 mg IV OD

01/11/22

HD done around 4:30pm

Inj. LEVIPIL ---> 500mg IV TID

Inj. MONOCEF---> 1gm IV BD

Inj. PAN ---> 40 mg IV OD

Inj ZOFER 4ng IV

Tab LASIX---> 40 mg PO OD

Strict I/O charting

Monitor BP,PR, temperature charting four hourly