Medicine case E log
Medicine case presentation
Monday, June 1st, 2020
Hello everyone.....!! I am an intern in medicine department and one of the important terms of getting the internship completion is to complete my log book with my daily log of what I learn during the course of my duties.
Case Discussion
A 65 year old female presented to Opd with chief complaints of
-Abdominal distension since 4 days
-Diffuse abdominal pain since 4 days
-decreased urinary output since 4 days
-Burning micturition since 4 days
-Constipation since 2 days
HOPI
Patient was apparently asymptomatic 4 days back then she developed burning micturition not associated with suprapubic tenderness, loin pain, fever and chills.
It is associated with decreased urinary output since 4 days.
Diffuse abdominal pain present since 4 days which was spasmodic type non radiating. No aggravating and relieved on medication.
Diffuse abdominal pain present since 4 days which was spasmodic type non radiating. No aggravating and relieved on medication.
There is history of fluid loss 4 days back ( vomitings 2 episodes )
Past History
She is a k/c/o DM type 2 since 6 months and is using medication for it (Metformin 500 mg OD)
She is a k/c/o HTN since 3 years and is on medication for it (T.atenolol 50mg and T.amlodipin 5mg)
Patient is not a k/c/o TB, Asthma, Epilepsy, CAD and CKD
Drug History
Not allergic to any known drugs.
Personal History
Diet : mixed
Appetite : normal
Sleep : adequate
Bladder : decreased urine output since 4 days
Bowel : constipation since 4 days
Family History
Not significant
General Examination
Patient is conscious,coherent and cooperative. Moderately nourished and well built.
Temperature : Afebrile
Pulse rate : 84bpm
BP : 110/70 mm hg
RR : 16 cycles per min
SPO2 : 96%
GRBS : 125mg%
No signs of pallor, icterus, cyanosis, clubbing, kilonychia, generalised lymphadenopathy.
h/o bilateral pedal edema progressing upto knee.
Respiratory system
Normal vesicular breath sounds heard
Bilateral air entry present
Dyspnoea- present (grade 2)
Wheeze- no
Position of trachea- central
Breath sounds- vesicular
Adventitious sounds- B/L coarse crepts
CVS
Cardiac sounds : S1 S2 heard
No murmurs heard
Per Abdomen
Shape : scaphoid, soft
no tenderness and local rise of temperature.
no palpable mass
hernial orifice : free
no free fluid , no bruits heard
liver and spleen - not palpable
bowel sounds- sluggish
CNS
Patient is conscious, coherent, cooperative well oriented to time place and person.
Higher mental functions- normal
cranial nerves- intact
motor system- normal
sensory system - normal
1. ABG
2. PT , APTT
3. BT, CT
4. RFT
5. LFT
6. CUE
7. Bacterial culture and sensitivity
8. USG
9. FBS
10. Chest x ray
Diagnosis :
Pre renal AKI with Urosepsis with hypoalbuminemia and k/c/o DM type 2 , HTN with Grade 2 fatty liver.
Treatment:
1) Inj pantop 40mg/iv/stat
2) Inj piptaz 4.5gm/iv/stat
3) Inj piptaz 2.25iv/qid
4) IVF U.O + 30ml/hr NS
5) GRBS 6th hourly Inj HAI sc
6) Inj lasix 20mg/IV/stat
7) Inj lasix 20mg/IV/bd if SBP > 110 mm hg
8) syp lactulose 30 ml bd if stools are not passed
9) maintain MAP > or = 65-70 mm hg
10) protein X powder 2 tbsp in one glass milk BD
11) 2 egg whites per day
12) BP, Temp, PR charting hourly
13) I/O charting strictly
Patient was sent to dialysis on 21/05/2020 , indication being anuria.
Follow up:
Following investigations were repeated :
1. ABG
2. Hemogram
3. CBP
4. Blood urea
5. Serum creatinine
6. RFT
1. ABG
2. Hemogram
3. CBP
4. Blood urea
5. Serum creatinine
6. RFT
Patient was sent to dialysis on 26/05/20 due to increased blood urea levels. Patient potassium levels were decreased and she was given syp potchlor.
Patient was sent to dialysis 01/07/20 due to increased blood urea and serum creatinine.
She was discharged on 02/07/20
Advice at discharge :
- Salt(<2g/day) and fluid (<1.5lit/day) restriction
-Tab nodosis 500mg bd
-Tab aldactone 50mg od
-Tab amlong 5mg od
-Tab shelcal 500mg od
-Syp potchlor 10ml in one glass of water tid for 2days
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