A 50 year old patient

Greetings to one and all who are currently reading my blog.  This is P.Ananya,third semester medical student

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Note: This is an ongoing case and will be uploaded as and when information is provided. This E-Log has been made under the guidance of Dr. Roshini ma’am

Case: A 50 year old female came to the casualty 

Chief complaints 

1. Pedal edema

2.SOB

3.decreased urine output

History of present illness

 

10 years ago she developed fever and got evaluated where they told she developed renal failure and started her on maintenance medication 

Urine output normal back then

No edema

H/O NSAIDS abuse intermittently for abt 3 months

Generalized edema ,SOB, since 2 months so hemodialysis was initiated here

She was fine until 10 haemodyalysis

Later developed loss of appetite and started losing weight 

Since 10 days

C/o generalized weakness

Unable to get up from bed

•severe nausea and vomiting (on consumption of non veg diet)

•fever on and off- high grade

•no urine output 

*pt on irregular HD...last done 10 days ago

History of past illness and treatment 

H/O hypertension since 25 years 

K/c/o hypothyroidism since 25 years

                                was on thyronorm 25ug

H/O hysterectomy 20 years ago

Family history 

Pts mother had DM

PERSONAL HISTORY 

Married

Regular bowels 

Abnormal micturition-reduced urine output 

No addiction

Diet

Mixed

Normal appetite

Non vegetarian 

GENERAL EXAMINATION:-

Patient is concious coherent and cooperative, moderately built ,moderately nourished 

• Pallorpresent 
• No icterus
• No cyanosis
• No clubbing
• No lymphadenopathy
• No edema.

Vitals:-

• Temp- afebrile.
• PR: 100 BPM.
• RR: 22 CPM.
• Bp: 140/90 mm Hg
• Spo2 : 98%
• GRBS 141 MG%.

SYSTEMIC EXAMINATION:-

A. Cardiovascular system 

• S1 S2 HEARD
• NO MURMURS.

B. Respiratory system 

• NVBS heard
•  BAE +
•  TRACHEA CENTRAL.

C. Per abdominal examination 

• Scaphoid shape

D. Central nervous system:-

1. Higher Mental Function:-

• Alert and conscious 
• Normal speech

2. Cranial nerves -

•  all cranial nerves 

                               - gag reflex
                               -  vulva position

3. Motor system - attitude -

                                       Rt.              Lt.  

        •Reflexes. B         +                 +

                          T          +                 +

                          S          +                 +

                          K          +                 +

                          A          +                 +

                     Plantars-flexors

                                         RFT 

COMPLETE BLOOD PICTURE 

ULTRASOUND report 

LFT:

ECG:

COMPLETE BLOOD PICTURE 

Bacterial culture and sensitivity report 

LFT

TREATMENT 

Day 1

15/08/21

                 1) T . NICARDIA      10MG      PO/BD

                 2)  T . NODOSIS      500mg     PO/BD

                 3) T . OROFERXT      PO/BD

                 4) T . SHELCAL  CT     PO/BD

                5) Inj.ERYTHROPOITIN    4000 IO

                    s/c , Weekly once

               6) Fliud restriction  < 1.54 /day

               7) Salt restriction    < 4gm/day

               8) TAB RIBOFLAVIN   10mg  PO/BD

              9) TAB BPLEX FORTE              PO/BD

             10) InJ . Monocef   1g/1V/BD

16/08/21

1)      TAB PCM

17/08/21

                  1) Inj . Pan 40mg IV/OD

                  2) Inj . Monocef  1gm IV/OD

                  3) Inj . Zofer 4mg IV/OD

                  4) Inj . Sodium bicarbonate IV 5amps in                                            NS  200ml

18/08/21

                   1) Inj . CEFTXIANE  1gm IV/BD

                   2) T LASIX 20mg Oral/BD

                    3) T MEYROGYL 50mg   PO/OD

                    4) T PCM 650 SOS

                    5) T UNRACET 1/2 QID

                     6) Inj . OPTINEURIN 1amp OD

 

19/08/21

1)                        Inj . Cepraxone 1gm IV BD

2)                          Inj . Optinueron 1amp IV OD

                            100ml NS

3)                         Inj . Erythropoitin 4000 IV/SC Weekly once

4)                         Inj . Pan 40mg IV  OD

5)                         Inj . Zofer 4mg IV TID

6)                          Inj . Vancomycin 1gm IV Start in through central line

7)                          Inj . Merponin 500mg IV OD

8)      T . Lasix 20mg P/O BD

9)      T . MET XL 5mg P/O OD

1     T .  PCM 650mg P/O SOS

       T .  Ultracet  1/2 tab P/O QID

        T .  NODODSIS 100mg P/O BD 

         T . AROPER XT  P/O BD