50 yr old female with decreased urine output.

June 03, 2021

GENERAL MEDICINE CASE (E log)

A 50 yr old Female with Decreased urine output.

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians signed informed consent.

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This Elog also reflects my patient centered online learning portfolio.

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 a diagnosis and treatment plan.

S. Prathyusha 8th sem roll no. 176

Case scenario

A 50 yr old female presented to casuality on 02/06/2021 with cheif complaints of 

a)decreased urine output since 1 week

b) fever since 1 week associated with sweating.

c) pedal edema since 1 week.

History of present illness

Patient was apparently asymptomatic 1month ago, then she developed fever which is on and off and is associated with cough and generalized weakness,Decreased urine output.

Fever is associated with sweating, chills and bilateral pedal edema since 1 week.

Associated symptoms

       Vomitings - 3-4 episodes per day for 3 days.

Past history

No H/o similar complaints in the past. 

known case of Hypertension since 10 yrs and hypothyroidism since 5 yrs. 

Been on medication ever since.

H/o NSAID usage.

PERSONAL HISTORY

diet - mixed

Appetite - normal

Sleep - adequate

Bowel and bladder movements - decreased output

ADDICTIONS - no

FAMILY HISTORY

Not significant

GENERAL EXAMINATION

Patient is conscious coherent cooperative well oriented to time ,place,person

Pallor -absent

Icterus - absent

Cyanosis - absent

Clubbing - absent

Lymphadenopathy - absent

Edema-bilateral pedal edema +ve

VITALS

Temperature -97°F

Heart rate -66bpm

Blood pressure -90/60mm of Hg

SYSTEMIC EXAMINATION

RS -bilateral air entry present

CVS-S1,S2 heart sounds heard

PA-soft and non tender

CNS-intact

INVESTIGATIONS

ECG

USG

HBsAg -positive

RFT

Blood urea-233mg/dl

Serum Creatinine -8.7mg/dl

Sodium -122mEq/l

Potassium -4.6mEq/l

Chlorine-86mEq/l

CBP:

Hb-13 gm

TLC-25,400 cells/cubicmm

 CUE

Reddish cloudy

Albumin - 4+

Sugar - trace

RBC - plenty

Serum osml - 320 osm/kg

TB - 0.77

DB - 0.16

AST - 10

ALT -10

Alkaline phosphatase - 170

TP - 7.0

On 3/6/2021 8.00 a.m

O/E pt conscious coherent cooperative 

Temp - 97 F°

PR - 66 bpm

BP - 90/60 mm of Hg

CVS - S1, S2 heard 

CNS - No abnormality detected  

P/A soft

PROVISIONAL DIAGNOSIS

RENAL AKI

acute glomerulonephritis

DENOVO DM Type 2 with Acidosis with HBsAg +ve

TREATMENT 

1)Inj Piptaz 2.25 gm iv /Tid 

2)Ivf Ns 5%D @ 100ml / hour 

3) Inj Pantop 90 mg Iv OD

4)Inj Zofer 4 mg IV SOS 

5)Inj HAI 1 ml in 49 ml NS @1ml/hr (increased or decreased acc to GRBS)

 6) TAB Paracetamol 500mg PO/SOS

7)T.Thyronorm 25 microgm PO/OD

8)GRBS hourly

9)BP/pR/Temp /RR 4th hrly

10)Strict i /o charting

On 3/06/2021

1)inj. Piptaz 2.25 gm iv /Tid 

2)inj. Lasix 20 mg/iv/if sbp > 110mm hg

3) tab. Nodosis 550mg/po/OD

4) tab. Shelcal 500mg/OD

5) tab. Orofer - XT /po/OD

6)strict I/O charting

7) salt and water retention

Questions

1)what are the causes of AKI?(including drugs)

2)how does hypothyroidism be a cause for AKI(mechanism)?

3) what are the other possible outcomes/ complications of a diabetic,HBsAg +ve patient??