40 Yr old Female with fever and pain abdomen since 7 days

 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.

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

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 omitt. 


Pt came to casualty with complaints of 
1.Fever since 1 week
2. Pain abdomen since 1 week

HOPI:
Pt was apparently asymptomatic 1 week back then she developed fever which was continuous, low grade associated with chills and relives on medication. 
Pt has pain abdomen since 1 week which diffuse type
Decreased urine output since 3 days
Nausea,vomiting since 2 days 4-5 episodes/day, subsided now
Increased frequency of stools 4-5 episodes/day since 2 days which is greenish, small quantity, mucoid, non fouls smelling
Facial puffiness, pedal edema-pitting type, grade-3, abdominal distention since 2 days
No H/O burning micturition, cough, SOB, trauma
Pt has no Pallor, icterus, cyanosis, clubbing, lymphadenopathy

Past H/O:
Similar complaints 1 month ago with burning micturition 
K/C/O Diabetes since 5 yrs on T.METFORMIN 500mg + T.GLIMIPERIDE 2mg + T.VOGLIBOSE 0.3
N/K/C/O HTN,TB,epilepsy,CAD,CVA
Hysterectomy done 10 years ago

Drug H/O:
H/O usage of T.Naxdom 250mg 3 days ago given by RMP
H/O usage of antacids since 2 years for recurrent peptic ulcer disease

Personal H/O:
Occupation:Housewife
Diet:mixed
Appetite: Decreased
Sleep: Decreased 
Bowel and bladder movements:
Decreased urine output and increased frequency of stools
No addictions

Vitals on admission:
Pt is C/C/C
Temp:98.6F
PR:72bpm
BP:160/90mmhg
RR:18/min
SPO2:98%
GRBS:74mg/dl
CVS:S1S2+
RS:BAE+
P/A:soft, tenderness right hypochondrium
CNS:N

Diagnosis: ACUTE KIDNEY INJURY (SECONDARY TO ACUTE GASTROENTERITIS)
FEVER UNDER EVALUATION
?DENOVO HYPERTENSION
OHA INDUCED HYPOGLYCEMIA 


INVESTIGATIONS:
On 12/11/22
Treatment: 
1.INJ.PIPTAZ 2.25gm IV/TID
2.INJ.PANTOP 40mg IV/OD
3.IVF NS @ urine output+30ml/hr
4.INJ.LASIX 40 mg IV/BD
5.Neb.ASTHALIN 2 repules STAT
6.INJ.ZOFER 4mg IV/BD
7.INJ.HAI SC ACCORDING TO GRBS
8.INJ.TRAMADOL 1 ampule+100NS IV/SOS
9.T.DOLO 650mg PO/SOS
10.T.SPOROLAC PO/BD
Day-2
1)INJ.PIPATEZ 2.25gm IV/TID
2)IV FLUIDS NS@ 50 ml/hr
3)INJ.PAN 40 MG IV /OD
4)INJ.LASIX 40MG IV/BD
5)INJ.ZOFER 4 MG IV/BD
6)TAB.SPORLAC PO/TID

Day-3
ICU BED 3
40/F
S:Pain abdomen ( diffuse) ,loose stools with mucus 8-10 episodes: yesterday
O: patient is conscious, coherent, co-operative
PR:98/min
BP:150/90 mm Hg
Temp:98.2 F
CVS:S1S2 Present
RS:BAE Present,NVBS
P/A:Soft,tenderness diffuse more at epigastric region
CNS:N

1)INJ.PIPATEZ 2.25gm IV/TID
2)IV FLUIDS NS@ 50 ml/hr
3)INJ.PAN 40 MG  IV /OD
4)INJ.LASIX 40MG IV/BD
5)INJ.ZOFER 4 MG IV/BD
6)TAB.SPORLAC PO/TID

Day-4

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