45 yr old female patient with complaints of vomiting since 10 days and H/o renal stones...

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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.

A 45 year old female patient came OPD with 

Chief complaints: Nausea & Vomiting since 10 days .

HOPI: Pt was apparently asymtomatic 10 days ago and then developed nausea and vomiting. 

Associated with decreases appetie and disturbed sleep.

She had 4-5 episodes per day in the last two days.

It occured few hours  after consumption of food.

Contents :- food particles 

DAILY ROUTINE : 

The patient wakes around 6 am and does all her household chores,cook food, prepare her kids for school and goes to do her work in field.

She has her lunch by 1 pm and then takes an half an hour rest and then gets back to work.

She returns home by 6pm , freshen up and then prepare dinner. 

She has her dinner with family by 8 pm then watches T.V. till 9:30 pm and then goes to sleep

EVENTS LEADING TO FIRST EPISODE OF VOMITING :

She woke up as per her daily routine and did all her household work went to work with her husband by afternoon after having her lunch she felt nauseous and had her first episode of vomiting.

Then 4 such episodes happen in quick succession even after consuming just water.

Then her husband got to the hospital.

PAST HISTORY : she is not a known case DM, HTN, TB

4 years ago she had complaints of burning micturition, fever and pedal edema for which she consulted a local doctor.

She was found to have right kindney stones with infection and simple right nephrectomy done in 2018.

Then she was adviced for a follow up every 6 months,which she did go for 2 yr years and then didnt due to personal reasons.

                                  SURGICAL SCAR

FAMILY HISTORY: No similar complaints in the family.

PERSONAL HISTORY: 

   Diet: mixed

   Appetite: normal

   Sleep: adeqaute 

   Bowel and bladder : regular

   Addictions : none

GENERAL EXAMINATION : 

Pt was conscious, coherent and cooperative.

She was well oriented time, place and person.

Pallor : present

Icterus : none

Cyanosis : none

Clubbing : none

Lymphadenopathy : none

Edema : none

VITALS

 BP : 130/80 mm hg

 PR : 82 bpm

 RR : 16 cpm

 TEMPERATURE : afebrile

 SPO2 : 98%

SYSTEMIC EXAMINATION :

 CVS : S1 &  S2 heard and no murmurs noticed

 Respiratory System : Bilateral air entry present and vesicular breath sounds heard.

Abdominal system : on inspection : normal.

                                   on palpation : no tenderness seen                                                                 in any quandrant.

                                    on auscultation : bowel sounds                                                                            heard.

CNS : no focal neurological defects seen.

INVESTIGATIONS :

USG - ABDOMEN : 4 Years ago

                           on 23rd june 2022

CBP : 

CUE : 

LFT :

RFT :

ECG :

ON 30/6/22:

Now she has B/L pedal edema extending upto knees and facial puffiness too.

                                  RIGHT LEG

                                       LEFTLEG 

INVESTIGATIONS ORDERED :

  HEAMOGRAM

 BUN

 RFT

                                   HEMOGRAM

                                          BUN

                                        RFT

On 4/7/22

 Vitals

 BP : 150/80 mm Hg

PR : 90 bpm

CVS : s1 and s2 heard

CNS : no focal neurogical defects

RS : BAE +

 Investigations done

BUN

S.Creatinine

Heamogram

COMPARISION OF PATIENT 14TH CONDITION 25th , 30th and 4th

Feature                25th               30th                      4th

Pedal edema     absent        present                  absent

                                              extending 

                                             upto kness

Hb                         13.7              6.9                        6.7

                        (Normal)      (decreased)       (decreased)

Urea                      113              101                        126

S.creatinine          6.0               6.9                        6.6

PROVISIONAL DIAGNOSIS :

AKI secondary to gastroenteritis.

TREATMENT :

27/6/22

Inj.PAN 40mg /IV /OD

Inj. METROGYL 50mg / IV /TID

Inj. ZOFER 4mg / IV

Tab. DOLO 650 mg

IVF NS @ 40 + 50 ml/hr

28/7/22 -4/7/22

T. LASIX 20mg / PO/BD

T. NODOSIS 500mg / PO/ BD

T. MVT /PO/OD

T. SHELCAL 500mg /PO/ OD

Cap. Bio-D3/PO/OD

T.NICARDIA 10mg /PO/BD ( on 4/7/22 )

Importance of dialysis in acute gastroenteritis induced aki.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8284204/