50 year female with AKI

 

 I’ve 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

NAME:- G VISHAL

ROLL NO :- 50

 50 year old female patient agriculture worker by occupation resident of nalgonda came to casuality with Cheif complaints of fever since 7 days , vomitings since 3 days and decreased urine output since 2 days

History of present illness:- patient was apprently asymptomatic 10 years back then she developed prolapse of uterus during delivery and was suggested for the surgery but the patient refused which progressed to the current shape and size

H/o pulmonary kochs 10 years back used ATT for 3 months 

Complaints of fever since 7 days which is low grade and associated with chills and reelived on using medication

Vomiting since 3 days , non projectile and not blood tinged and food as content

Complaints of cough with sputum white in color and is associated with shortness of breath which is subsided now

Complaints of burning micturation since 3 days associated with decreased urine output and not associated with hesitency , urgency , increased frequency 

Also complaints of pain in abdomen since 7 days and aggravated when uterus prolapses and pain is dragging type increased since 1 year

Past history :- N/K/C/O DM , HTN , CVA , CVD 

Personal history:- 

Diet :- mixed 

Appetite :- normal

Bowel and bladder movements :- regular

Sleep :- adequate

General examination:- patient is conscious, coherent, cooperative.

Vitals at presentation :- 

Bp:- 110/60mmhg

Pr:- 78bpm

Rr :- 19cpm

Spo2 :- 98%

Temp:- 97.8

No pallor , icterus , cyanosis , clubbing, lymphadenopathy 

Sytemic examination:- 

Cvs :- s1 s2 heard 

Rs :- decreased breath sounds in left IAA crepts heard at left ISA 

P/A :- soft non tender

Investigations :- 

Necessary investigations were done 

Ecg :- 

Culture and sensitivity :- 

Usg abdomen :- 

Hrct chest :-  

Chest xray :- 

Referals :- 

Obs and gync referal:-

Provisional Diagnosis :- 

1. Viral pyrexia under evaluation 

2 acute kidmey injury non oliguric ?renal? Post renal

3 uterovaginal prolapse (3 degree)

4 left upper lobe large bulla communicating with left  upper lobe bronchus

5 bilateral mild pleural effusion (rt>lft)

6 H/o pulmonary kochs (drug defaulters 10 years back)

Plan of care:- 

1 IV FLUIDS NS ( urine output plus 30ml/hr)

2 INJ LASIXS 20mg IV BD 

3 TAB PANTOP 40mg sos 

4 TAB DOLO 650mg PO SOS 

5 SYP ASCORIL LS 10ml PO TID

6 INJ MONOCEF 1gm IV BD

7 TAB ALDACTONE 25mg PO OD 

8 DAILY VAGINAL PACKING BD

9 STRICT I/O CHARTING

10  VITALS MONITORING 6th hourly