65 Y/F WITH COMPLAINT OF ABDOMINAL PAIN
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 box.
19 th January 2023
Date of admission: 12/01/23
CHIEF COMPLAINT:
65 years old female patient resident of Nalgonda,labourer by occupation presented to casualty with chief complaints of:
Abdominal pain since 2 days
Associated with nausea and vomiting since 1 day
HISTORY OF PRESENT ILLNESS:
-Patient was apparently asymptomatic 2 years back then she developed pedal edema, facial puffiness, distension of abdomen, decreased urine output, shortness of breath and difficulty in moving lower limbs 2 years back and was taken to a private hospital and diagnosed to have hypokalemic periodic paralysis (k+:2.2) and found to have raised creatinine and was started on conservative management.
-1 year back patient started walking with support and decreased pedal edema and facial puffiness and patient developed decreased urine output and diagnosed with CKD ( grade III RPD changes, increased creatinine, shrunken kidney,anemia ) and started on conservative management.
-2 months back pain abdomen, decreased appetite, burning micturition and cloudy urine for 6 days subsided on medication.
-2 days back pain abdomen developed on taking food- all over /diffuse, squeezing type not associated with loose stools.
Vomiting of Non bilious ,non projectile, 2 episodes, food particles as content,no blood tinged.
H/o fever with chills
No h/o rigors, cold and cough
Dialy routine:
Wakes up at 6 am and takes bath and have breakfast (rice,roti) by 8 am and goes to work work and takes lunch at 12:30 pm and goes back to work upto 4-5 pm she sleeps at 8am after having dinner (rice,dal)
PAST HISTORY:
Not a K/C/O DM, TB, HTN , EPILEPSY,ASTHMA.
No h/o past surgery
H/o Blood transfusion 2 months back by 2PRBC
FAMILY HISTORY:
No similar complaints in family
PERSONAL HISTORY:
Diet:mixed
Appetite: normal
Sleep: adequate
Bowel and bladder movements : normal
Burning micturition is present
Addictions: Alcohol occasionally (stopped 10 years back)
GENERAL EXAMINATION:
Patient is conscious coherent and cooperative
and well oriented to time,place and person.
Patient is thin built and moderately nourished
No pallor
No icterus
No cyanosis
No clubbing of fingers
No generalised lymphadenopathy
Vitals:
Temperature:Afebrile
Pulse Rate: 90 bpm
Blood Pressure: 120/70 mmHg
Respiratory Rate: 20 cpm
SYSTEMIC EXAMINATION:
->CARDIOVASCULAR SYSTEM:
No Thrills
S1,S2 sounds hears
No murmurs.
->RESPIRATORY SYSTEM:
INSPECTION:
Size and shape: bilaterally symmetrical and elliptical
Position of Trachea:central
No supraclavicular hollowing
No usage of accesory muscles of respiration
Apical impulse is not seen
Chest expansion: symmetrical
PALPATION:
Trachea:midline
No intercoastal widening or narrowing
Chest movement: symmetrical
Measurement of chest expansion:
Whole thorax:35.5cm
Right Hemi Thorax:17cm
Left hemi thorax : 17 cm
Position of apical beat at 5th intercostal space , 1 inch medial to midclavicular line.
Tactile vocal fermitus is equal on both sides
PERCUSSION:
No tenderness over chest wall, no crepitations, no palpable added sounds, no palpable pleural rub
AUSCULTATION:
Vesicular breath sounds
No wheeze
Vocal resonance:normal
->ABDOMEN:
INSPECTION:
Contour: flat
shape-scaphoid
Apperance of Umbilicus-inverted and central position
Surface:No dilated veins
Pigmentation:No scars and sinuses
Respiratory movement of abdomen walls is normal
PALPATION:
Superficial palpation:
Feel of abdomen: elastic
Non tenderness
No Local rise of temperature
Deep palpation:
No palpable Mass
Spleen and liver not palpable
PERCUSSION :
No fluid thrill
No shifting dullness
ASCULTATION:
Bowel sounds-present
->CNS:
Concious
Speech normal
Gait normal
Sensory system normal
Motor system normal
->Oral examination:
Patient have no teeth
INVESTIGATION:
Chest x-ray:
ECG:
PROVISIONAL DIAGNOSIS:Acute kidney injury on chronic kidney disease
Diagnosis:
Urinary tract infection and aki on ckd
TREATMENT:
T.LASIX 40MG PO/OD
T.SHERCEF 500MG PO/OD
CAP.BIO D3 PO/Once weekly
T.OROFER ×T PO/OD
Inj.EPO 4000 iu S/C /Once weekly
T.NODOSIS 500MG PO/BD
syp.CITRALKA 15ML PO/HS
T.DOLO 650MG PO/SOS
Inj.MONCEF 1GM /IV/BD
