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

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