65 years old female with Abdominal pain and vomiting
17th January 23
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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. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here 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
65 years old female patient who is from nalgonda labor by occupation presented to OPD on 12-01-23
CHEIF COMPLAINTS:
Abdominal pain since 2days
Associated with nausea and vomiting since 1day
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 2 years back then she developed pedal edema, facial puffiness, decreased urine output short ness of breath and difficulty in moving lower limbs 2 years back and was taken to a private hospital and diagnosed to have hypokalemic (k+2.2) and found to have raised creatinine levels
1 year back patient started walking with support and decreased pedal edema and facial puffiness and decreased urine output and diagnosed with CKD ( increased creatinine, shrunken kidney,anemia)
2months back pain abdomen, decreased appetite, burning micturition and cloudy urine for 6 days subsided on medication.
2days back pain abdomen - squeezing type not associated with loose stools
Vomiting,nausea and pain abdomen Non bilious ,non projectile, 2 episodes, food particles as content.
PAST HISTORY:
N/K/C/O DM, TB, HTN , EPILEPSY,ASTHMA.
No history of past surgery
Blood transfusion 2months back 2prbc
FAMILY HISTORY:
No similar complaints in family
PERSONAL HISTORY:
APPETITE : decreased
DIET: mixed
SLEEP : Adequate
BOWEL AND BLADDER : regular
MICTURITION : decreased
Addictions: Alcohol occasionally (stopped 10 years back)
GENERAL EXAMINATION:
Patient is conscious coherent and cooperative, well oriented to time,place and person.
Thin built and moderately nourished
No signs of Icterus cyanosis, clubbing , Lymphadenopathy.
Pallor:present
Vitals
Temp:afebrile
PR: 90 bpm
Bp: 120/70 mmHg
RR: 20 cpm
Systemic Examination:
CARDIOVASCULAR SYSTEM:
No Thrills,
S1,S2 sounds hears,
No murmurs.
RESPIRATORY SYSTEM:
INSPECTION:
Chest is symmetrical
Trachea:central
No drooping of shoulders
No supraclavicular hollowing
PALPATION:
Trachea:central
No intercoastal widening or narrowing
Chest movement: symmetrical
Measurement of chest expansion
Whole thorax:35.5cm
Hemi Thorax:17cm
AUSCULTATION:
Vesicular breath sounds
No wheeze
ABDOMEN:
INSPECTION:
shape-scaphoid
Flanks-free
Umbilicus-inverted and central position
No dilated veins
No scars and sinuses
PALPATION:
Non tender
No Local rise of temperature
No palpable Mass
Spleen and liver not palpable
PERCUSSION :
No fluid thrill
No shifting dullness
AUSCULTATION:
Bowel sounds-present
CNS:
Concious
Speech normal
Gait normal
Sensory system normal
Motor system normal
Provisional Diagnosis:
Acute kidney injury on chronic kidney disease
Investigations
Treatment
T.LASIX 40MG PO/OD
T.SHELCAL 500MG PO/OD
CAP.BIO N PO/Once weekly
T.OPOFER ×T PO/OD
Inj.EPO 4000 iu S/C /Once weekly
T.NODOSIS 500MG PO/BD
syp.CITRALKA 15ML PO/HS
Syp. MUCALINEGEL PO/BD
T.DOLO 650MG PO/SOS
Inj.MONCEF 1GM /IV/BD
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