1701006124 CASE PRESENTATION
LONG CASE
A 55yrs old female house maid by occupation came to the hospital on 9th june with
Chief complaints:
•Fever since 5days
•Headache since 5days
• neck stiffness since 4days
History of present illness:
Patient Was apparently asymptomatic 5days ago then she developed fever sudden in onset continuous type and relieved on medication associated with generalized body pains
Fever was not associated with chills and rigors.
Headache since 5days insidious in onset and throbbing type and progressive relieved on medication .
Neck stiffness since 4days.
History of vomiting 3days back 1episode non projectile non bilious content food particles.
No history of photophobia , seizures.
No history of cough , cold, loose stools , abdominal pain, sob
No history of burning of micturition.
Past history:
No history of similar complaints in past.
Not a known case of diabetes,Hypertension ,Asthma , tuberculosis, Thyroid.
Hysterectomy done 25yrs ago.
Family history:
No Similar complaints in family
No history of Dm , hypertension.
Personal history:
Diet: mixed
Appetite: decreased
Sleep: Adequate
Bowel and bladder: regular
No addictions and allergies.
General examination:
Patient is conscious coherent co operative well oriented to time, place ,person.
She is moderately built and well nourished.
No pallor,icterus, cyanosis, clubbing ,lymphadenopathy,edema.
Vitals:
Temperature:99°F
Bp:75bpm
PR:75bpm
RR:17cpm
Spo2:96%
Systemic Examination:-
CENTRAL NERVOUS SYSTEM EXAMINATION.
cranial nerves -
1-sense of smell - present
Motor system
Meninges :
Sensory system -
all sensations pain, touch, temperature, position, vibration sense are well appreciated .
Cerebellar signs:
Heel knee incoordination : no
Finger nose incordination: no
CARDIOVASCULAR SYSTEM
INSPECTION:
Chest wall - bilaterally symmetrical
No dilated veins, scars, sinuses
PALPATION:
•Apical impulse is felt on the left 5th intercostal space 1cm medial to mid clavicular line.
•No parasternal heave, thrills felt.
PERCUSSION:
Right and left heart borders are percussed.
AUSCULTATION:
•S1 and S2 heard , no added thrills and murmurs heard.
RESPIRATORY SYSTEM
INSPECTION:
Chest is bilaterally symmetrical
Trachea – midline in position.
Apical Impulse is not appreciated
Chest is moving normally with respiration.
No dilated veins, scars, sinuses.
PALPATION:
Trachea – midline in position.
Apical impulse is felt on the left 5th intercoastal space.
Chest is moving equally on respiration on both sides
Tactile Vocal fremitus - appreciated
PERCUSSION:
The following areas were percussed on either sides-
Supraclavicular- resonant
Infraclavicular- resonant
Mammary-resonant
Axillary-resonant
Infraaxillary-resonant
Suprascapular-resonant
Infrascapular-resonant
interscapular- Resonant
AUSCULTATION:
Normal vesicular breath sounds heard
No adventitious sounds heard.
ABDOMEN EXAMINATION
PALPATION:
PERCUSSION:
AUSCULTATION:
Provisional diagnosis:-
Investigations:
Fasting blood sugar- 168 mg/ dlHb1 AC -6.9
CUE:
Albumin +Sugar - nil Pus cells - 6 - 8Epithelial cells- 3-4RBC - nilCasts - nil
CSF :
Sugar - 81Protein-12.6Chloride-113
On day 10th /6:- Vitals:-
Temperature: 99°FPulse rate: 76bpmResp rate:15cpmBP:130/90mmhgSpo2:96%
GRBS- 197mg/dl
On day 11th/6:-
Vitals:- Temperature: 99°FPulse rate: 78bpmResp rate:16cpmBP:120/90mmhgSpo2:96%
GRBS- 190mg/dl
On 12th /6-
Vitals:-Temperature: Afebrile Pulse rate: 76bpmResp rate:16cpmBP:130/90mmhgSpo2:96%
GRBS- 168mg/dl
Treatment-
◇Inj. CEFTRIAXONE 2 gm/ BD
◇Inj.DEXA 6mg/iv/tid
◇Inj . Vancomycin 1gm/iv
◇Inj. Pcm 1gm/iv
◇Tab . Pcm 650 mg
◇Tab. Ecospirin 75 mg /po/od
◇Tab. Atorvas 10 mg /po/od
◇Syp. Cremaffin plus 30ml/po
◇Oint.Diclofenac for thigh pain
◇Inj.pan 40 mg iv /od
◇Tab. Naproxen 250 mg po/tid.
◇Flexbenz gel for L/A on thighs
-------------------------------------------------------
SHORT CASE
A 65 year old female patient came to the hospital with the
Cheif complaints :
•Low back pain since 7 days
•Redued urine output since 7 days
A 65 year old female patient came to the hospital with the
Cheif complaints :
•Low back pain since 7 days
•Redued urine output since 7 days
History of Presenting Illness:
Patient was apparently asymptomatic 4 years ago then she developed low back pain of cramping type aggravated on working and was relieved on medications .
Since then, she used to take the medications when the pain appears again.
Patient 2yrs ago with the burning micturition, lower back pain complaints went to a hospital, which on investigations were told to have renal failure. She didn' t take any treatment for it.
Patient presents with decreased urine output and low back pain since 7 days.
Patient Complaints of fever of low grade, intermittent in nature and relieved on medication. It was associated with burning micturition.
No history of chills and rigors, shortness of breath and pedal edema.
Patient was apparently asymptomatic 4 years ago then she developed low back pain of cramping type aggravated on working and was relieved on medications .
Since then, she used to take the medications when the pain appears again.
Patient 2yrs ago with the burning micturition, lower back pain complaints went to a hospital, which on investigations were told to have renal failure. She didn' t take any treatment for it.
Patient presents with decreased urine output and low back pain since 7 days.
Patient Complaints of fever of low grade, intermittent in nature and relieved on medication. It was associated with burning micturition.
No history of chills and rigors, shortness of breath and pedal edema.
Past History:
NSAIDs abuse since 4 years
Medical history:
Not a known case of Diabetes mellitus, Hypertension. Epilepsy, Cardiovascular disease,. Asthma and tuberculosis.
Surgical history:
Had Hysterectomy for a prolapsed uterus 4 yrs back
NSAIDs abuse since 4 years
Medical history:
Not a known case of Diabetes mellitus, Hypertension. Epilepsy, Cardiovascular disease,. Asthma and tuberculosis.
Surgical history:
Had Hysterectomy for a prolapsed uterus 4 yrs back
Family History:
No similar complaints in family
Not significant
No similar complaints in family
Not significant
Personal history:
Diet: mixed
Appetite:decreased
Sleep: Adequate
Bowel and bladder : Decreased urine output
No known allergies
No addictions
Diet: mixed
Appetite:decreased
Sleep: Adequate
Bowel and bladder : Decreased urine output
No known allergies
No addictions
General examination:
Patient is conscious, cooperative and well oriented to time, place and person. She is of thin built.
• pallor-present
•Icterus-absent
•Cyanosis-absent
•Clubbing- absent
•Edema- absent
•Lymphadenopathy- absent
Patient is conscious, cooperative and well oriented to time, place and person. She is of thin built.
• pallor-present
•Icterus-absent
•Cyanosis-absent
•Clubbing- absent
•Edema- absent
•Lymphadenopathy- absent
Vitals:
Temperature:afebrile
Pulse rate: 95 bpm
Blood pressure: 110/70 mm of Hg
Respirtaory rate; 16 cpm.
Temperature:afebrile
Pulse rate: 95 bpm
Blood pressure: 110/70 mm of Hg
Respirtaory rate; 16 cpm.
Systemic Examination:
ABDOMEN EXAMINATION
ABDOMEN EXAMINATION
INSPECTION:
•Shape – scaphoid
•Flanks – free
•Umbilicus –central in position , inverted.
•All quadrants of abdomen are moving equally with respiration.
•No dilated veins, hernial orifices, sinuses
•No visible pulsations.
•Shape – scaphoid
•Flanks – free
•Umbilicus –central in position , inverted.
•All quadrants of abdomen are moving equally with respiration.
•No dilated veins, hernial orifices, sinuses
•No visible pulsations.
PALPATION:
•No local rise of temperature and tenderness
•All inspectory findings are confirmed.
•No guarding, rigidity
•Deep palpation- no organomegaly.
•No local rise of temperature and tenderness
•All inspectory findings are confirmed.
•No guarding, rigidity
•Deep palpation- no organomegaly.
PERCUSSION:
•There is no fluid thrill , shifting dullness.
Percussion over abdomen-
tympanic note heard.
•There is no fluid thrill , shifting dullness.
Percussion over abdomen-
tympanic note heard.
AUSCULTATION:
Bowel sounds are heard.
CARDIOVASCULAR SYSTEM
Bowel sounds are heard.
CARDIOVASCULAR SYSTEM
INSPECTION:
•Chest wall - bilaterally symmetrical
•No dilated veins, scars, sinuses
•Chest wall - bilaterally symmetrical
•No dilated veins, scars, sinuses
PALPATION:
•Apical impulse is felt on the left 5th intercostal space 1cm medial to mid clavicular line.
•No parasternal heave, thrills felt
•Apical impulse is felt on the left 5th intercostal space 1cm medial to mid clavicular line.
•No parasternal heave, thrills felt
AUSCULTATION:
•S1 and S2 heard , no added thrills and murmurs heard.
RESPIRATORY SYSTEM
•S1 and S2 heard , no added thrills and murmurs heard.
INSPECTION:
•Chest is bilaterally symmetrical
•Trachea – midline in position.
•Apical Impulse is not appreciated
•Chest is moving normally with respiration.
•No dilated veins, scars, sinuses.
•Chest is bilaterally symmetrical
•Trachea – midline in position.
•Apical Impulse is not appreciated
•Chest is moving normally with respiration.
•No dilated veins, scars, sinuses.
PALPATION:
•Trachea – midline in position.
•Apical impulse is felt on the left 5th intercoastal space.
•Chest is moving equally on respiration on both sides
•Tactile Vocal fremitus - appreciated
•Trachea – midline in position.
•Apical impulse is felt on the left 5th intercoastal space.
•Chest is moving equally on respiration on both sides
•Tactile Vocal fremitus - appreciated
PERCUSSION:
The following areas were percussed on either sides-
• Supraclavicular-resonant
•Infraclavicular- resonant
•Mammary- resonant
•Axillary- resonant
•Infraaxillary- resonant
•Suprascapular- resonant
•Infrascapular- resonant
• interscapular - resonant.
The following areas were percussed on either sides-
• Supraclavicular-resonant
•Infraclavicular- resonant
•Mammary- resonant
•Axillary- resonant
•Infraaxillary- resonant
•Suprascapular- resonant
•Infrascapular- resonant
• interscapular - resonant.
AUSCULTATION:
•Normal vesicular breath sounds heard
•No adventitious sounds heard.
CENTRAL NERVOUS SYSTEM EXAMINATION.
HIGHER MENTAL FUNCTIONS:
•Patient is Conscious, well oriented to time, place and person.
•Normal vesicular breath sounds heard
•No adventitious sounds heard.
CENTRAL NERVOUS SYSTEM EXAMINATION.
•Patient is Conscious, well oriented to time, place and person.
•All cranial nerves - intact
•Motor system: Intact
•Superficial reflexes and deep reflexes are present , normal
•Gait is normal
•No involuntary movements
•Sensory system -
-All sensations pain, touch,temperature, position, vibration, are well appreciated.
•Motor system: Intact
•Superficial reflexes and deep reflexes are present , normal
•Gait is normal
•No involuntary movements
•Sensory system -
-All sensations pain, touch,temperature, position, vibration, are well appreciated.
Provisional Diagnosis:
•Acute Kidney Injury on Chronic Kidney Disease .
Investigations
Hemogram:
Complete urine examination:
Renal function tests:
Serum electrolyte:
Ultrasound report: Impression:Grade 1 Rpd changes in rightkidneyGrade 2 Rpd changes in left kidney Bilateral renal cortical cysts
Ultrasound report:
Bacterial culture and sensitivity:
•Blood urea: 117mg/dl•Serum iron:72ug/dl•Serum albumin:3g/dl•Serum creatinine: 8.8mg/dl•Rbs: 80mg/dl
Treatment:
◇Tab. LASIX 40 mg PO BD
◇TAB. NODOSIS 500mg PO BD
◇TAB. OROFER XT PO BD
◇TAB. PAN 40mg PO OD
◇TAB. ULTRACET 1/2 TAB PO QID
◇INJ. IRON SUCROSE 1Amp in 100 ml NS ONCE WEEKLY
◇INJ. EPO 5000IU/SC/OD
◇SYRUP. CRANBERRY 15ml PO TID
◇Tab. LASIX 40 mg PO BD
◇TAB. NODOSIS 500mg PO BD
◇TAB. OROFER XT PO BD
◇TAB. PAN 40mg PO OD
◇TAB. ULTRACET 1/2 TAB PO QID
◇INJ. IRON SUCROSE 1Amp in 100 ml NS ONCE WEEKLY
◇INJ. EPO 5000IU/SC/OD
◇SYRUP. CRANBERRY 15ml PO TID
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