Shortcase-A 60 yearold female with decreased urine output.

SHORT CASE(PRACTICAL FINAL EXAMINATION)

Hallticket no:1701006159

A 60 yearold female patient with reduced urine output.

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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, and investigations, and come up with a  diagnosis and treatment plan.

CASE PRESENTATION

A 60 year old female patient came to OPD with the complaints of

      Reduced urine output since 7 days

       Shortness of breath since 7 days

 History of presenting illness:

4years back:

Patient was apparently asymptomatic 4 years back when she developed high grade fever for which she visited a local hospital and was diagnosed with UTI.Patient was advised for some surgery but patient denied it and was on conservative treatment.

She also had joint pains for which she was given NSAIDs

7 days back:

Patient was admitted to our OPD with 

*decreased urineoutput 

*SOB which was grade 2 in nature

*Complains of fever of lowgrade ,intermittent in nature and releived on medication.

*No history of chills ,rigor and pedal edema

Past history:

Patient had similar complaints in the past since 3 years

  Not a known case of Diabetes mellitus, Epilepsy, Cardiovascular diseases,asthma and tuberculosis.

Past surgical history:

4 years back patient had hysterectomy for prolapsed uterus.

Past drug history:

Patient took NSAIDS for 4 years.

Family history:

Not significant.

Personal history:

Diet: Mixed diet.

Apetite:Normal

Sleep: Adequate.

Bowel habits:regular

Bladder habits:decreased urine output

No allergies and addictions.

Examination was done after taking consent from the patient.

General examination: Patient is conscious, cooperative and well oriented to time, place and person. She is moderately built.

 Pallor is present.

  No signs of icterus, cyanosis, clubbing. lymphadenopathy and edema are present.

            

Vitals:

 Patient is afebrile

 Pulse rate: 90 bpm

  Blood pressure: 110/70 mm of Hg

  Respiratory rate:18 cpm

Clinical images:

Systemic examination:

ABDOMINAL EXAMINATION:

 INSPECTION:

Shape – scaphoid

Flanks – free

Umbilicus –central in position , inverted.

All quadrants of abdomen are moving equally with respiration.

No dilated veins, hernial orifices, sinuses

No visible pulsations.

 PALPATION

No local rise of temperature and tenderness

All inspectory findings are confirmed.

No guarding, rigidity

Deep palpation- no organomegaly.

 PERCUSSION:

There is no fluid thrill , shifting dullness.

Percussion over abdomen- tympanic note heard.

 AUSCULTATION:

 Bowel sounds are heard.

CARDIOVASCULAR SYSTEM:

INSPECTION:

Chest wall - bilaterally symmetrical

No dilated veins, scars, sinuses

Apical impulse and pulsations cannot be appreciated

 PALPATION:

Apical impulse is felt on the left 5th intercostal space 1cm medial to mid clavicular line.

No parasternal heave, thrills felt

 AUSCULTATION:

S1 and S2 heard , no added thrills and murmurs heard.

 RESPIRATORY SYSTEM

 INSPECTION:

Chest is bilaterally symmetrical

Trachea – midline in position.

Apical Impulse is not appreciated 

 Chest is moving normally with respiration.

No dilated veins, scars, sinuses.

 PALPATION:

Trachea – midline in position.

Apical impulse is felt on the left 5th intercoastal space.

Chest is moving equally on respiration on both sides

Tactile Vocal fremitus - appreciated 

 PERCUSSION:

The following areas were percussed on either sides- 

Supraclavicular

Infraclavicular

Mammary

Axillary

Infraaxillary

Suprascapular

Infrascapular

Upper/mid/lower intersacapular

All are resonant

 

AUSCULTATION:

Normal vesicular breath sounds heard 

No adventitious sounds heard.

 

CENTRAL NERVOUS SYSTEM EXAMINATION.

 

HIGHER MENTAL FUNCTIONS:

 Patient is Conscious, well oriented to time, place and person.

All cranial nerves - intact

Motor system: Intact

Superficial reflexes and deepreflexes are present 

Gait is normal

No involuntary movements

Sensorysystem- All sensations (pain, touch, temperature, position, vibration sense)  are   well appreciated.  

PROVISIONAL DIAGNOSIS:Acute kidney injury on chronic kidney disease.

       

INVESTIGATIONS:

Hemogram:

 Hemoglobin: 7.7 gm/dl

  RBC count: 2.77 millions/cumm (3.8-4.8)

  Total Leucocyte Count: 5800 cells/cumm

   Lymphocytes: 17 (20-40)

Complete urine examination:

Blood urea:

Serum creatinine:

Serum Iron:

Ultrasound :

1)Grade 1 RPD in right kidney

2)Grade 2 RPD changes in left kidney

3)Bilateral cortical cysts

 Treatment:

Tab. LASIX 40 mg PO BD

TAB. NODOSIS 500mg PO BD

TAB. OROFER XT PO BD

TAB. PAN 40mg PO OD

TAB. ULTRACET 1/2 TAB PO QID

INJ. IRON SUCROSE 1Amp in 100 ml NS ONCE WEEKLY

INJ. EPO 5000IU/SC/OD

SYRUP. CRANBERRY 15ml PO TID