Skip to main content

 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 inputs on the comment"

SHAIK. Ishrath parveen, Roll no. 187

December 16, 2021

57 YEAR FEMALE WITH DECREASED URINE OUTPUT AND SHORTNESS OF BREATH

57 YEAR FEMALE WITH DECREASED URINE OUTPUT AND SHORTNESS OF BREATH 

15/12/21 

A 57 year old female patient presented to the OPD with chief complaints of decreased urine output since 3 days and shortness of breath grade II-III since one day And fever not associated with chills and rigors 


HISTORY OF PRESENT ILLNESS

✓57 year old female patient resident of sirikonda,, housewife . She was apparently asymptomatic 3 years back then she had low back pain which was radiating to groin diagnosed as renal caliculi managed conservatively.... f/b diagnosed with CKD managed conservatively 

✓Decreased urine output since 3days 
Sob grade II-III since yesterday night
Cough with sputum yellowish in colour intermittent f/b blood tinged sputum 
And fever not associated with chills and rigors 

PAST HISTORY:

No similar complaints in the past

 MEDICAL HISTORY:

Not a know case of diabetes, hypertension, tuberculosis, epilepsy, asthma.

FAMILY HISTORY:

No relevant family history

PERSONAL HISTORY:

-Mixed diet
-REDUCED APPETITE
-Adequate sleep
-Regular bowel movements
-micturition: Pt HAS DECREASED URINE OUTPUT.

GENERAL PHYSICAL EXAMINATION:
PALLOR - Present

Icterus - Absent
Cyanosis - Absent
Clubbing - Absent
Lymphadenopathy - Absent
Pedal oedema - PRESENT (NON PITTING TYPE)

Vitals:
Temperature- afebrile
Pulse rate- 89 beats per minute
Respiratory rate- 22 breaths per minute
B.P- 110/70 mm hg
SpO2- 90% at room air

SYSTEMIC EXAMINATION

Cardiovascular system- s1 and S2 are heard no murmurs are heard

Respiratory system:
Dyspnoea- present
Breath sounds- decreased breath sounds in right 
Vesicular breath sounds are normal
Wheezing- present

Rt side Fine Crepts present 
BAE- positive

Central nervous system- Patient was conscious coherent and cooperative.
Speech was normal.
No slurred speech
No meningeal irritation signs 

-No abnormality detected.

REFLEXES

Right and left biceps triceps supinator ankle and knee show grade 2 Reflex

GAIT - Normal


PROVISIONAL DIAGNOSIS:

CKD with right sided pleural effusion

            TREATMENT:


1.Pleural tap
2. Head and elevation up to 30°
3. O2 supplementation if SpO2 is less than 90%.
4. Fluid restriction < 1 litre per day
5. Salt restriction < 2.4 G per day
6.Inj. Augmentin 500 mg/ IV/ OD
6. Tab. Azithromycin 500 mg/ OD
7. Inj. Lasix 40 mg IV/ BD
8. Tab
9. Tab shelcal 500 mg audi
10. Tab orofer-xT /OD
11. Inj. Erythropoietin 4000 IU s/c weekly once
12.Inj. Iron sucrose 1Amp in 100 ml us during dialysis
13.Syrup. Ascoryl 10ml /TD
14. Monitor vitals hourly
15. Strict I/O Charting, 



SR LDH --255IU/DL 
PLEURAL LDH--1968IU/DL 
SR PROTEINS 5.4 G/DL 
PL PROTEIN 3.6 G/DL 
PL SUGAR 71 MG/DL

Pl ldh /sr ldh -1968/255 =7.7 
Pl protein /sr protein -3.6/5.4 =0.66

Spot urine protein 53mg/dl. 


One session of dialysis done 


            
PLAN FOR DIALYSIS

Comments

Post a Comment

Popular posts from this blog

60 YEAR OLD MALE CKD ON MAINTENANCE HEMODIALYSIS WITH ANEMIA OF CHRONIC DISEASE WITH HYPERTENSION

Image
This is an a 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 This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted A 60 year old male, who is a resident of Nalgonda ,farmer by occupation came with   Chief complaints: -Pedal edema since 3 months -shortness of breath since 20 days - decreased  urine output since 15 days History of presenting illness: The patient was apparently asymptomatic 3 months back when
Read more

77Y M with swelling on the left leg

Image
A patient named aged 77 years came to opd Chief complaint :  swelling on left leg since 15 days, low grade fever since 15 days History of present illness  :  patient was apparently asymptomatic 15 days ago, then he developed swelling in his left leg           -which is insidious in onset,           - gradually progressive           -no relieving or aggravating factors Low grade fever since 15 days          - not associated with chills and rigors          -no cough and cold          - relieved on medication No shortness of breath No palpitations, chest pain History of trauma is present Past history :           Known case of hypertension since 8 years Not a known case of diabetes mellitus , epilepsy, thyroid Had cellulitis,necrotizing infection 6 years ago on left leg Had a accident with car 9 years ago,had a tibia implant 9 years ago, it was removed 5 years ago Personal history :            -mixed diet            -regular bowel and bladder movements            - adequate sleep        
Read more

Gm case (20 years)

Image
 GENERAL MEDICINE 20-12-22 This is an online E log book to discuss our patient's de-identified health data shared after taking his /her/guradian's consent. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box below. DATE OF ADMISSION :19-12-22 A 20 old male student from miryalaguda came to OPD with CHIEF COMPLAINTS : backache since 1 day, neck pain since 2 days. HOPI:patient was apparently asymptomatic 3 days back, then he developed fever which is inscidious  in onset, low grade, intermittent not relived on medication. He developed neck pain 2 days back which is dragging type and was inscidious in onset, gradually progressive, non radiating and  no relieving and aggrevating factors, which was not associated with vomitings, giddiness loss of consciousness.  Back pain since 1 day which was sudden in onset in the lower lumbar region and  pricking type,  continuous, no aggrevating and relieving factors -no h/o burni
Read more