A 65 year female,came with the chief complaints of vomitings.

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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. 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.

Chief complaints:

Vomitings since 1 week.

Burning micturation and decreased urine output since 1 week.

History is taken from attender(reliable)and partly from patient.

HOPI:

Patient was apparently asymptomatic 20years ago,then she developed shortness of breath every year during winter season and subsided after medication.

Then,she developed neck pain,backache and bilateral knee joint pains since 3-4years for which she is taking ayurvedic medicine and pain killers-1 to 2 tablets per episode.

Then she developed low grade fever which is intermittent, assosiated with chills,rigor and generalised weakness and  temporarily relieved on medication.

H/o nausea and vomitings since 1week,which is non-bilious,non projectile,2-3 episodes per day,which made her weak and was taken to local RMP,where she was treated with Saline infusion and Paracetamol and was referred to our hospital for testing where she was diagnosed with Hypertension.

H/o burning micturation and decreased urine output since since 1 week.

PAST HISTORY:

No similar complaints in the past.

She is a known case of hypertension which was diagnosed 1 week back.

Not a known case of Diabetes,TB, Epilepsy.

SURGICAL HISTORY:

She underwent Cataract surgery in right eye 7 years back.

PERSONAL HISTORY:

Diet:Mixed 

Appetite: Decreased since 14days

Sleep: Disturbed 

Bowel and bladder movements used to regular but decreased since 1 week.Burning micturation present since 1 week.

No addictions.

FAMILY HISTORY:

No relavent family history.

DRUG HISTORY:

History of some unknown medications which helped her in relieving her SOB every winter(anti histamines??)

History of pain killer(unknown) usage for recurrent episodes of neck pain,back pain and knee pains,2-3 tablets per day per episode.

GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent, cooperative,well oriented to time place and person.She is moderately built and nourished.

No signs of pallor, icterus, cyanosis, clubbing generalised lymphedenopathy and pedal edema.

Vitals:

Temperature:97.4F

Pulse rate:82bpm

Respiratory rate:16cpm

B.P:120/80 mmHg.

Systemic examination:

CVS:S1,S2 Heard,no murmurs.

RS: Bilateral air entry present.NVBS Heard.

Per abdomen:Soft,non tender and no organomegaly.Bowel sounds heard.

CNS:Higher motor functions intact 

Cranial nerves intact 

Power:5/5 in all four limbs 

Tone:Normal in all four limbs.

INVESTIGATIONS:

28/11/2022

 04/12/2022,

USG:

Interpretation:

Right renal calculi at PUJ causing hydronephrosis of same kidney.

Mild hydronephrosis noted in left kidney.

PROVISIONAL DIAGNOSIS:

Post renal AKI-Secondary to right PUJ calculus,hyperkalemia corrected, Seizures secondary to uremic encephalopathy

TREATMENT:

28/11/22

 Inj. Human actrapid Insulin -10 units

 

29/11/22

Lasix - 40mg PO BD

Orofer- PO OD × 7 days

Shelcal - 500 mg PO OD

Paracetamol -650 mg PO SOS

ZOFER - 4mg IV stat 

30/11/22,

Central line done.

Dialysis ( 29/11/22):- during which she experienced a seizure (around 11pm [29th]-12 am[30/11])episode which was controlled by

    LEVIPIL -1g IV stat

    OPTINEURIN 1g IV stat

Then she was intubated 

  Given

  Inj. ATRACURIUM 

  Inj. DEXAMETHASONE

Inj. LEVIPIL - 500mg IV TID

Inj. MONOCEF- 1gm IV BD

Tab LASIX- 40 mg PO OD

Tab OROFER-PO OD

Tab SHELCAL- 500mg PO OD

Tab PCM- 650mg PO SOS

Inj. OPTINEURIN

Inj. PAN -40 mg IV OD 

01/11/22

HD done around 4:30pm

Inj. LEVIPIL - 500mg IV TID

Inj. MONOCEF- 1gm IV BD

Inj. PAN -40 mg IV OD

Inj ZOFER 4ng IV

Tab LASIX-40 mg PO OD

Strict I/O charting

Monitor BP,PR, temperature charting four hourly 

2/12/2022,

Inj.LEVIPIL 500mg,iv,bd 

Inj.PAN 40mg,iv,od 

Inj.MONOCEF 1gm,iv,bd 

inj.ZOFER,4gm,iv 

Tab.LASIX 40mg,per oral,bd 

Inf.NS 

Tab.NICARDIA 10mg,po,od 

Syrup.ARYSTOZYME 10ml,po,tid 

Syrup.ASCORYL 10ml,po,tid 

Tab.ULTRACET 1/2 Tab,po,qid 

03/12/2022,

DJ stunting done,

Tab.NICARDIA,10ml,po,bd 

Inj.LEVIPIL,500mg,po,bd 

Tab.LASIX 40mg,po,bd 

Tab.MONOCEF 1gm,iv,bd 

Syrup.ARYSTOZYME 10ml,po,tid. 

04/12/2022,

Tab.LEVIPIL 500gm,po,bd 

Inj PAN 40mg,iv,od 

Inj.ZOFER,4mg,iv 

Tab.LASIX,20mg,po,bd 

Tab.NICARDIA,20mg,po,bd 

Syrup ASCORIL 15ml,po,tid 

Syrup CREMAFFIN,10ml,po 

Inj.MAGNEX FORTE,1.5gm,iv,bd 

Tab.PARACETAMOL,650mg,po 

Monitor vitals 4th hourly..