a 45 year old female elog.

This is an 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 patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centered online learning portfolio and your valuable comments in comment box are welcomed.



A 45 year old female came to the casuality with chief complaints of 

Pedal edema and shortness of breath since 15 days

Facial puffiness and abdominal distension


History of present illness

Shortness of breath since 1 week , orthopnea + and PND +( paroxysmal nocturnal dyspnea)  and loss of appetite and  no change  in urine output, no oliguria, no burning micturition

History of past  illness

K/C/O denovo hypertension  since 1 week and was on tab. Telma- H medication

N/k/c/o diabetes ,asthma ,epilepsy ,CAD

h/o covid infecttion 3 months back and was home isolated


General examination 

Pallor present

Icterus absent

Cyanosis absent

Bilateral pedal edema present

Lymphadenopathy absent 


Vitals 

Pulse rate - 98/min

Respiratory rate -    /min

BP 160/80 mmHg

SpO2 99%


Systemic examination :

 CVS

 No thrills heard. 

Cardiac sounds S1, S2 heard. 

Cardiac murmurs absent. 


Respiratory system

Dyspnea present

Wheezing absent

Trachea central in position

NVBS heard


Abdominal examination 

Scaphoid shape of abdomen

Tenderness present

Liver not palpable

Spleen not palpable

Bowel sounds heard. 


CNS examination 

Patient is conscious and coherent.

Speech normal. 


Reflexes

                Right.         Left

Biceps.  ++                 ++

Triceps.  ++                 ++

Supinator. ++              ++

Knee.           ++             ++

Ankle.         ++               ++



Cerebral signs. 

Finger nose in coordination - yes

Knee heal in coordination - Yes

Investigations:

From CUE : albumin presence in urine

From CBP: Normocytic normochromic anemia with leukocytosis and thrombocytopenia

From ultrasound: raised echogenecity of bilateral kidneys, urinary bladder distended minimally

 serum creatine: 10.6mg/dl (normal- 0.5-1.1)

Blood urea: 279mg/dl ( normal : 12-42)

serum K+: 7mEq/l (normal :3.5-5.1 )

ABG: pCO2-15.5mmHg( normal :35-45)











Provisional diagnosis : 

AKI ? Hyperkalemia k/c/o HTN

Treatment









DAY 1, 2,3

  • Fluid restriction <1.5 ltr/day, salt restriction < 2gm/day
  • Inj LASIX 40mg/IV/BD
  • TAB.AMLONG 5mg/PO/OD
  • BP CHARTING 4th hrly
  • TAB.NODOSIS 550mg/PO/OD
DAY 4,5

along with the previous treatment there is addition of
  • Inj.OPTINEURON 1amp in  100 ml/NS/OD
DAY 6
 
The same treatment with exclusion of BP CHARTING 4th hrly

Comments

Post a Comment

Popular posts from this blog

OSCE PREFINAL EXAMINATION

Image
Date :1/12/ 2023 Case blog: http://vasavipakker.blogspot.com/2023/11/female-with-break-bone-fever.html 25 yr old female housewife by occupation  resident of nalgonda came to general medicine OPD with  Chief complaints:- Body pains since 6 days Fever since 3 days On examination: Hess test positive . NS 1 antigen detected PROVISIONAL DIAGNOSIS:   Dengue fever LINK: http://vasavipakker.blogspot.com/2023/11/female-with-break-bone-fever.html WHAT ARE THE NEWER MODALITIES FOR TREATING DENGUE?? DOXYCYCLINE link:https://journals.lww.com/jfmpc/fulltext/2022/06000/effect_of_doxycycline_and_doxycycline_with_carica.161.aspx#:~:text=The%20study%20results%20indicate%20that,and%20to%20minimize%20hospital%20stay Doxycycline is a derivative of tetracycline that possesses broad antimicrobial and antiinflammatory activities. Further, antiviral activity of doxycycline has been reported against retroviruses, and a significant reduction in retrovirus titre was observed after incubation of infected cells wit
Read more

Vasavi 100

  BIOMONTHLY ASSIGNMENT -JUNE 2021 This is a bio monthly blended assignment of general medicine regarding the cases presented in the month of june . The assignment is the review of the cases . QUESTION 1 competency tested for peer review  https://amishajaiswal03eloggm.blogspot.com/ PULMONOLOGY Case 1:https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html Review: This is a case of a 55 yr old female patient with provisional diagnosis of acute exacerbation of COPD associated with heart failure and brochiectasis. The patient came with the chief complaints of shortness of breath , pedal edema and facial puffiness. she also has the history of type 1 diabetes mellitus and hypertension. The presentation of the investigation  regarding the diagnosis were presented in an order. The anatomical localization of the problem is at the brochioles due to exposure to dust or allergens in the paddy feilds.  NEUROLOGY Case 2:https://143vibhahegde.blogspot.com/2021
Read more

facial puffiness and edema of limbs

Image
This is an online E logbook 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 an available global online community of experts to solve those patients clinical problems with collective current best evidence-based inputs. This e-log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box are welcome. a 53-year-old male, a Hotel owner and chief by occupation, The patient presented to the hospital with chief complaints of Swelling of both Legs since 10 days Swelling of face since 7 days HISTORY OF PRESENTING ILLNESS   The patient was apparently asymptomatic 10 days ago.In the first week of June he had a binge of alcohol on occasion of local festival. Later he observed abdominal distension, followed by Bilateral Pedal odema which is pitting type extending up to the knee, insidious in gradually pr
Read more