65 year old female with complaints fever, vomitings and with a recently diagnosed hypertension......

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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.

65 year old female a resident of pochampally came to our department with

CHIEF COMPLAINTS :

1) c/o fever since 10 days 

2) c/o nausea and vomitings since 5 days

3) burning micturition 

Note : patient is very weak and couldnt tell history properly therefore her history was given by her daughter ( reliable source).

HISTORY OF HER PRESENTING ILLNESS : 

Patient was apparently normal 30 years ago then she had an episode of shortness of breath during winter season and it is not associated with cough, sputum, and was subside after taking medication which she follows till this year during every winter season since then.

    Then she developed developed neck pain, back ache and bilateral knee joint pain  3- 4years ago for which she is taking ayurvedic medicine and pain killers, monthly 15 to 20 times.

 Since the past 1 month she was experiencing generalised weakness and generalised body pains.

Then she developed low grade fever of intermittent type  since 10 days associated with nausea and vomiting since 5 days

Her back ache aggrevated since her fever attack and was radiating to the loin

COURSE OF RECENT EVENTS: 

PAST HISTORY:

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

N/K/C/O DM, TB , EPILEPSY

NO H/O PAST SURGERIES

FAMILY HISTORY:

No similar complaints in family 

PERSONAL HISTORY: 

  BUILT  : moderate

  APPETITE : decreased since 10 days

  DIET: mixed 

  SLEEP : disturbed

  BOWEL : regular

  BLADDER : decrease and burning micturition

She has a pretty sedentary lifestyle she wakes up in then morning freshes up takes her breakfast then does some bhajan at home then eats lunch then takes some rest and then eats her dinner then goes to her sleep.

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 -- present

                               icterus -- absent

                       B/L pedal edema : absent

VITALS 

TEMP : 98.6 ⁰C

BP : 140/80 mm hg

RR : 20 cpm post extubation

PR : 108 bpm

SPO2 : she is on nasal oxygen

SYSTEMIC EXAMINATION:

CVS:-

s1 and s2 heard ,no murmurs 

RESPIRATORY SYSTEM:- 

Central position of trachea 

Vesicular breath sounds

BAE+

No abnormal breath sounds,no dyspnea

ABDOMEN:

Scaphoid shape

Slight tenderness 

No bowel sounds

Couldn't do deep palpation as the patient was in pain and weak

INVESTIGATIONS : 

Hemogram : 

 ON 23RD OF NOVEMBER 2022 :- ALBUMINURIA WAS NOTICED

ABG :

CUE + SERUM ELECTROLYTES + RBS :

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.

INPUT AND OUTPUT :- 

DIFFERENTIALS:

  1) AKI ? ( Infection of renal stones--> post renal AKI + Hydronehrosis) 

  2) GLOMERULO NEPHRITIS ?

  3) NSAID ABUSE ----> RENAL DAMAGE?? ---> CKD

  4) AKI ON CKD ?

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 (around 11pm [29th]-12 am[30/11])episode which was controlled by

    LEVIPIL ---> 1g IV stat

    OPTINEURIN 1g IV stat

Then she was intubated 

  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