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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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.
4-March-2022
65 yr old female came with C/o
---Burning micturition since 4-5 days
---Decreased urine output since today morning
---Pedal edema since 5-6 hrs
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 4 to 5 days ago then she developed
BURNING MICTURITION
No h/o Loin pain , pain abdomen, fever & chills , vomitings, diarrhoea, itching in genital region, white discharge .
C/o DECREASED URINE OUTPUT since one day, only few drops of urine was passed & went to the outside Hospital where the treatment of INJ. LASIX 40 mg was given after which she passed the urine
No h/o fever, vomitings,diarrhoea
No h/o hematuria
C/o bilateral PEDAL EDEMA , insidious in onset, gradually progressive, pitting type , grade 2 ( upto knees).
No h/o of exertional dysnea, orthopnea , PND,
NO h/o of jaundice , pruritus , facial puffiness
HISTORY OF PAST ILLNESS:
k/c/o HTN since 6yrs & using T.TELMA mg OD
N/k/c/o of Dm, BA, TB, EPILEPSY, CVA , THYROID DISORDERS .
PAST SURGICAL HISTORY :
Hysterectomy 4yrs ago.
PERSONAL HISTORY :
Diet : mixed
Appetite : normal
Sleep : adequate
Bowel & bladder habits : regular, Burning micturition +
No known addictions
EXAMINATION :
Pt is c/c/c
Pallor -Absent
Cyanosis -Absent
Clubbing of fingers/toes -Absent
Edema of feet - Present
Icterus -Absent
Lymphadenopathy -Absent
VITALS :
TEMP : 98.6 f
HR : 75bpm
BP : 140/80 mm hg
RR : 18cpm
SPO2 : 98 % @RA
GRBS: 111mg/dl
P/A : soft, obese ,suprapubic tenderness+
CVS : s1, s2 + . No murmurs
RS : bae + NVBS +
CNS : NAD
INVESTIGATIONS :
CBP :
Hb: 11.5
TLC:10,400
PLT: 5.57
N/L/M/E: 55/37/5/3
LFT :
TB-0.98
DB-0.18
AST -25
ALT- 20
ALP-175
TP-6.8
A/G - 3.9
RFT :
SR.Cr - 1.1
Na+/k+/cl- : 131/3.6/98
ECG
DIAGNOSIS : Uncomplicated Urinary tract infection
TREATMENT :
1) IVF NS & RL @urine output + 30ml / hr
2) INJ. PANTOP 40mg i.v BD
3) Inj. LASIX 20mg i.v BD
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