Final Exam short case

General Medicine blog

Final Exam short case

February 07, 2022

This is an online e log book to discuss our patient de- identified health data shared after taking his/her guardian signed informed consent .He 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 elog also reflects my patient centered online learning protofolio and your valuable inputs on comment box is welcome.

PREETHII

I NISCHALA

VISIT PROFILEArchive

eport Abse

A 35year old female Of manipaka, came to casualty with the Cheif complaint of b/l pedal edema since 20 days,decreased urine output since 20 days,Facial puffiness , shortness of breath fever spike +, 10 days back, not associated with chills and rigor, subsided on taking medication.Complaint of cough with expectoration, yellowish in colour,

HISTORY OF PRESENT ILLNESS: patient was apparently asymptomatic 2 months back then she developed chest pain for which she visited local hospital in miryalaguda , on evaluation she was diagnosed to have chronic kidney disease and low hemoglobin, 2PRBC Transfusions were done 

After PRBC transfusion she developed b/l pedal edema, which subsided on medication.,

20 days back she developed b/l pedal edema, reduced urine output, sob a/w orthopnea,and facial puffiness. 

10 days back she developed fever a/w chills and rigor, which subsided on medication.

1 PRBC transfusion done in Nalgonda hospital yesterday.

Known case of HTN since 3 year's

PAST HISTORY: Not a known case of DM, asthma, TB.

PERSONAL HISTORY : 

Mixed diet 

Appetite :normal 

Bowel and bladder: decreased urine output 

No addiction

GENERAL EXAMINATION:

patient is concious ,coherent , cooperative 

Pallor - present

Icterus - absent

Cyanosis - absent

Clubbing - absent

Lymphadenopathy - absent

Pedal edema - b/l present

VITALS :

Afebrile

Bp: 170/100 mm hg

PR: 99 bpm

RR: 22 cpm

SpO2: 87% @RA

CVS: S1,S2 +

RS: BAE+

P/A: SOFT, NON TENDER

CNS: NAD

Pedal Edema: 

Reports : 

PROVISIONAL DIAGNOSIS:-

AKI on CKD

TREATMENT 

1. Head end elevation upto 30'

2. O2 supplementation if SpO2 < 90%

3. Inj. Lasix 40mg iv tid 

4. Inj. PIPTAZ 2.25gms IV BD ( D1)

5. TAB. NICARDIA 10MG PO BD 

6. TAB. NODOSIS 550MG PO BD 

7. TAB. SHELCAL 500 MG PO OD 

8. NEB. WITH SALBUTAMOL 2 RESIPULES / 4TH HRLY,

9. INJ. ERYTHROPOIETIN 4000 IU S/C WEEKLY ONCE 

10. SYP. ASCORYL PO TID