Welcome and greetings to every one who are visiting my blog. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.
A 40year old female came to the opd with chief complaints of fever since 1week and pain in abdomen since one weekHOPI:
Pt was apparently asymptomatic 1 week back then she developed fever which was continuous, low grade associated with chills and relives on medication
Pt has abdominal pain since 1 week which is diffuse
Decreased urine output since 3 da
Nausea,vomiting since 2 days 4-5 episodes/day, subsided
Increased frequency of stools 4-5 episodes/day since 2 days which is greenish, small quantity, mucoid, non foul smelling
Facial puffiness, pedal edema-pitting type, abdominal distention since 2 days.
No H/O burning micturition, cough, SOB, trauma.
Past history:
Similar complaints 1 month ago with burning micturition
K/C/O Diabetes since 5 yrs
on Medication
METFORMIN 500mg + T.GLIMIPERIDE 2mg + T.VOGLIBOSE 0.3
N/K/C/O HTN,TB,epilepsy,CAD,CVA, asthma.
Hysterectomy done 10 years ago.
Drug History:
H/O usage of T.Naxdom 250mg 3 days ago given by RMP
H/O usage of antacids since 2 years for recurrent peptic ulcer disease
Personal History:
Diet:mixed
Appetite: Decreased
Sleep: Decreased
Bowel and bladder movements:
Decreased urine output and increased frequency of stools
No addictions
General examination:
Pt has no Pallor, icterus, cyanosis, clubbing, lymphadenopathy
Vitals:
Pt is concious cooperative coherent and well oriented to time place and person
Temp:98.6F
PR:72bpm
BP:160/90mmhg
RR:18/min
SPO2:98%
Systemic Examination:
CVS:S1S2+
RS:BAE+
P/A:soft, tenderness right hypochondrium
CNS: No focal deficits, sensory motor systems are normal
Provisional Diagnosis:
ACUTE KIDNEY INJURY (SECONDARY TO ACUTE GASTROENTERITIS)
INVESTIGATIONS:
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