PATIENT WAS BROUGHT TO CASUALITY WITH ALTERED SENSORIUM

PATIENT WAS BROUGHT TO CASUALITY WITH ALTERED SENSORIUM SINCE 1 DAY. PATIENT WAS APPARENTLY ALRIGHT 20 DAYS BACK THEN HE HAD ANASARCA AND AND WENT TO LOCAL HOSPITAL WHERE IT WAS DIAGNOSED AS CKD UNDERWENT 6 SESSIONS OF DIALYSIS IN THE LAST DIALYSIS PATIENT IS UNABLE TO LIFT HIS LEG ON WALK SINCE DAY ONE PT HAD IRRELEVANT TALK 

PAST HISTORY: K/C/O DM 2 10 YEARS ON MIXTARD 

K/C/O HTN 20 DAYS NICARDIA 20 MG

 GENERAL EXAMINATION: 

THE PATIENT IS CONSCIOUS, COHERENT, COOPERTIVE, WELL ORIENTED TO TIME, PLACE AND PERSON MODERATELY BUILT AND NOURISHED NO SIGNS OF PALLOR, ICTERUS, CYANOSIS, CLUBBING, EDEMA, LYMPHADENOPATHY 

VITALS: TEMP: 99.7 F 

PR: 100 BPM 

RR: 20 CPM 

BP: 90/60 MM HG

SPO2: 95% @ RA 

GRBS: 113 MG/DL 

CVS: S1,S2 HEARD, NO MURMURS 

RS: NVBS

 PA: SOFT AND NON TENDER

 CNS: NFND 

OPHTHALMOLOGY REFERRAL WAS DONE ON 25/07/2023 I/V/O RAISED ICT CHANGES AND THEY EVALUATED THE CASE AND GAVE THE IMPRESSION THAT THERE WAS NO RAISED ICT OR DIABETIC RETINOPATHY OR HYPERTENSIVE RETINOPATHY IN BOTH THE EYES



PROVISIONAL Diagnosis

 CKD WITH SEPSIS 



Investigation 

CBP 27/7/23 

HB 8.8 

TC 12600 

PCV 25.9 

PLT SMEAR- ADEQUATE IN DISTRIBUTION

 PLT COUNT 1.76

 UREA 45 

S CREAT 6.8 

NA+ 138 

K+4.1 

CL- 99

 HIV HBSAG HCV NON REACTIVE BACTERIAL CULTURE AND SENSITIVITY REPORT: - URINE FOR CS: 2-3 PUS CELLS SEEN; ENTEROCOCCUS SPP >10^5 CFU/ML OF URINE ISOLATED - BLOOD FOR CS: NO GROWTH AFTER 24 HOURS OF AEROBIC INCUBATION USG ABDOMEN GRADE 1 RPD CHANGES NOTED IN BILATERAL KIDNEY 2D ECHO REPORT SCREENING - RWMA POSITIVE LAD HYPOKINETIC RCA WITH LCX HYPOKINESIA - MILD LVH POSITIVE 1.22 CM - MILD TO MODERATE MR; NO MS - MILD AR; NO AS/MODERATE TR WITH MILD PAH - EF= 40%. RVSP= 40+10 = 50 MM HG 

- MODERATE LV DYSFUNCTION - MILD PE - DIASTOLIC DYSFUNCTION - IVC SIZE (1.77 CM) DILATED NON COLLAPSING - DILATED RA/LA - MILD DILATED RV/LV MRI PLAIN BRAIN BILATERAL SMALL SUBCORTICAL WHITE MATTER HYPERINTENSITIES- NON SPECIFIC/ AGE RELATED



Treatment Given

REGULAR HEMODIALYSIS FUID RESTRICTION LESS THEN 1.5 L PER DAY SALT RESTRICTION LESS THAN 2GM PERDAY

 TAB.NICARDIA 20 MG PO/TID 

TAB.CLONIDINE 0.1MG PO/TID 

TAB LASIX 40 MG PO/BD 

TAB.SHELCAL CT PO /OD 

TAB.NODOSIS 500MG PO/BD 

TAB.OROFERXT PO/OD 

INJ.EPO 4000 IU SC WEEKLY ONCE 

Comments

Post a Comment

Popular posts from this blog

14 yr old female with shortness of breath

Image
 This 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. 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. This is a case of a 14 year old girl who came with chief complaints of: Shortness of breath since 2 days Fever since 1 day Abdominal pain since 1 day Vomiting 1 episode HOPI:  The patient was apparently asympt
Read more

PATIENT WITH C/O SOB SINCE 7 DAYS

PATIENT WITH C/O SOB SINCE 7 DAYS  PATIENT WAS APPARENTLY ASYMPTOMATIC 7 DAYS AGO THEN HE DEVELOPED SOB OF INSIDIOUS ONSET GRADUALLY PROGRESSIVE AND AGGRAVATED SINCE PAST 2 DAYS COUGH + WITH EXPECTORATION,BLOOD TINGED + FEVER + SINCE 7 DAYS ,LOW GRADE NOT WITH CHILLS AND RIGOR,COLDSORE THROAT -, ABDOMINAL PAIN -,VOMITING -,LOOSE STOOLS - N/KC/O CVA,CAD,TB,EPILEPSY K/C/O TB SINCE 7 YEARS AGO USED MEDICATION K/C/O HTN AND DM II SINCE 2 YEARS ON MEDICATION PERSONAL HISTORY APETITE-DECREASED SLEEP-ADEQUATE BOWEL AND BLADDER- REGULAR NO ALLERGIES  GENERAL EXAMINATION; PATIENT IS CONSIOUS ,COHERENT,COOPERATIVE  NO SIGNS OF PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,EDEMA  VTALS PR-108 BPM BP- 120/60 MMHG RR-22 CPM  TEMP AFEBRILE SYSTEMIC EXAMINATION :  CVS : S1 S2 HEARD , NO MURMURS  RS : BAE +,RHONCI ?  PER ABDOMEN : SOFT , NON TENDER , NO ORGANOMEGALY  CNS : HGHER MOTOR FUNCTIONS PRESENT , NO FND  PULMONOLOGY REFFERAL DONE I/V/O BLOOD TINGED SPUTUM AND PREVIOUS TB ADVISED TRUNAAT,HRC
Read more

PATIENT PRESENTED TO CASUALTY WITH C/O FEVER SINCE 1 WEEK, VOMITINGS SINCE 1 WEEK

 PATIENT PRESENTED TO CASUALTY WITH C/O FEVER SINCE 1 WEEK, VOMITINGS SINCE 1 WEEK( 4 EPISODES/DAY) NAUSEA PRESENT NON COMPLIANCE TO MEDICINE FOR 3 DAYS LAST WEEK AND FOR 3 DAYS THIS WEEK  HOPI: PATIENT WEAS APPARENTLY ASYMPTOMATIC 1 WEEK AGO THEN SHE DEVELOPED FEVER OF LOW GRADE WITH CHILLS AND RIGORS ,INTERMITTENT WITH VOMITINGS( 4 EPISODES PER DAY ) ,NON PROGRESSIVE ,NON BILIOUS ,CONTAIN FOOD PARTICLES AS CONTENT K/C/O DM2 SINCE 20 YEARS( USING METFORMIN 500 MG PO/OD) K/C/O HTN SINCE 20 YEARS( USING TELMIKIND 40 MG PO/OD ,NOT USING SINCE 3 DAYS)  ON EXAMINATION: PT IS C/C/C NO SIGNS OF PALLOR,ICTERUS,CLUBBING,CYANOSIS,LYMPHEDENOPATHY,PEDAL EDEMA VITALS: TEMP: 98.2  PR-100 BPM  BP: 140/80 MM HG  RR: 16 CPM  CVS: S1, S2+,NO MURMURS  RS: BAE +, PROVISIONAL Diagnosis  DIABETIC ACIDOSIS SECONDARY TO NON COMPLIANCE (RESOLVED) WITH AKI ON CKD SECONDARY TO LEFT HYDROURETRONEPHROSIS WITH HYPERKALEMIA(RESOLVED) WITH DILATED CARDIOMYOPATHY WITH HFMEF(EF 4%) WITH HYPONATREMIA (RESOLVED) WITH K/
Read more