Long case final practical

 This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.


Monday,June 6th


A 80year old male came with Fever,Vomiting,oliguria.


B.Sushma ,9th semester

Hallticket number: 1701006021

June 6th,2022


A CASE DISCUSSION ON Fever,Vomiting,oliguria.


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 a diagnosis and treatment plan.


CASE PRESENTATION:


A 80yr old male, resident of marrigudam, farmer by occupation presented to our opd on  31st may 2022 with

CHEIF COMPLAINTS of

C/O Fever  since 3days

C/O  decreased urine output since 2days

C/O vomiting 2days back 



HISTORY OF PRESENT ILLNESS:





  • Patient was apparently asymptomatic 10yrs back then he developed fever associated with chills insidious in onset ,gradually progressive with no diurnal variations and  relieved on medication and  also decreased urine output , burning micturition is  present then he went to a   hospital there he was told as renal failure(AKI) and 2sessions of dialysis was done.

From then he was on medication with diuretics(Tab.Furosemide) as he was suffering from oliguria.

  • Later he developed recurrent  episodes of fever associated with chills and also burning micturition which was relieved by tablets given by local hospital.

  •  Now 8days  ago  he developed 

FEVER insidious in onset ,gradually progressive with no diurnal variations and relieved on medication associated with chills and generalised body pains . It is not associated with cough ,cold and night sweats.


Decreased urine output  and there is burning micturition which is experienced at the start of urinary flow and relieved after urination and is not associated with any hematuria.


H/o vomiting of 1episode 7days ago with food particles as content and non bilious and non foul smelling.


Later sob since 6days which is of insidious in onset,gradually progressive, of grade 3 (NYHA)developed  associated with wheezing,pedal edema.


no orthopnea,no paroxysmal nocturnal dysuria

  • No h/o facial puffiness  
  • No H/O loin pain 


PAST HISTORY 


K/c/o HTN since 24years and is on regular treatment of Tab.Telmisartan 40mg


NO DM,ASTHMA,CAD


Nephrectomy was done 27yrs ago donated  left kidney to his brother.


   

PERSONAL HISTORY 


Marital status - married 


Occupation - Farmer


Appetite - Decreased 


Diet - Mixed 


Bowel and bladder movements - decreased and oliguria associated with burning micturition and feeling of incomplete voiding.


Addictions - he was occasional alcoholic  and smoker  27 years back smokes  daily 2-4 beedis per day. And after nephrectomy was done he quit smoking.


No significant family history .


GENERAL EXAMINATION :


Patient is conscious , coherent, cooperative and well oriented to time ,place ,person.

moderately built and nourished.

 

Pallor present


pedal edema present


No icterus , cyanosis , lymphadenopathy



VITALS

Temp:Febrile


BP : 140/ 90mm Hg(on medication)measured in supine position in both arms .


PR : 86/ Min normal voulme ,regular rhythm,normal character ,no radiofemoral delay,radioradial delay.


RR : 18/ Min


SPO2: 97% on RA


GRBS:106mg/dl





SYSTEMIC EXAMINATION


CARDIO VASCULAR SYSTEM : 

  • Elliptical and bilateral symmetrical chest 
  •  No visible pulsations,engorged veins,scars,sinuses on the chest wall.
  • No raised JVP.
  • Apex beat palpable at 5th intercostal space  medial to midclavicular line .
  • S1, S2 heard.
  • No murmurs.

RESPIRATORY SYSTEM: 

  • Shape of chest is elliptical and b/l symmetrical
  • Trachea appears to be central
  • Expansion of chest equal on both sides
  •  BAE + , diffuse wheeze+
  • Vesicular  breath sounds heard. 

PER ABDOMEN : 

  • No abdominal distention, visible pulsations,engorged veins,scars,sinuses.
  • soft , nontender ,no organomegaly.
  • Bowel sounds present.

CNS : 


  • Higher mental functions intact.
  • No signs of meningeal irritation.
  • Sensory system :Normal
  • Motor System :Normal
  • Cranial nerves :Intact
  • Reflexes: Right.     Left. 

Biceps.      ++.          ++

Triceps.    ++.          ++

Supinator ++.         ++

Knee.         ++.         ++

Ankle        ++.         ++

  • Gait: normal


Clinical pictures:






















INVESTIGATIONS:


Complete Blood Picture:

On31/05  4:36PM

On31/05 11:00PM



HEMOGRAM
On 1/06


On 2/6


On 3/6


LFT:



Serum electrolytes:




RFT:


On 31/05

Serum creatinine:9.1mg/dl

Blood urea:164mg/dl


On 1/06





Complete urine examination:


Plenty of pus cells seen
ECG


USG



USG report:

  •  Raised echogenicity of right kidney
  •  Normal size of kidney
  •  Mild hydronephrosis
  •  Not visible left kidney

Urine culture and sensitivity:


2D Echo




Provisional diagnosis - 



AKI  (2° to urosepsis) on CKD might be due to recurrent urinary tract infection.




TREATMENT:

1.INJ.LASIX 40 mg IV/BD 

2.INJ PIPTAZ 4.5gm IV/STAT 

3.INJ.PANTOP 40 mg IV/OD

4.INJ ZOFER 4 MG IV/SOS

5.INJ  NEOMOL 100ml/IV/SOS

6.NEB.BUDECORT 12 HRLY 

            DUOLIN 6 HRLY 

7.TAB. DOLO 650mg/TID

8.CREMAFFIN syrup 15ml PO/SOS

9.STRICT I/O CHARTING 

10.BP,TEMPERATURE MONITORING 4 HRLY












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