30 year old female with AKI on CKD and k/c/o SLE
roll no: 55
I've 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.
Following is the view of my case:
29 year old female who is a customer service executive by occupation, came to the hospital with chief complaints of vomitings since 3 days and loose stools since 3 days.
HOPI:
Patient was apparently asymptomatic 3 days ago, then she developed loose stools since 3 days (3-4 episodes/day) , watery in consistency and not associated with fever and pain abdomen. Complaints of vomitings since 3 days (2-3 episodes/ day) which were yellowish and contained food particles, non projectile, not blood stained.
Past history:
3 months ago she got admitted in our hospital with complaints of sudden worsening of SOB and was diagnosed with acute cardiogenic pulmonary edema with immune mediated glomerulonephritis and seizures secondary to ?PRES /? Uremia /? Vasculitis.
Known case of SLE with lupus nephritis since 2 months and is on
Rabeprazole + domperidone
Tab orofer xt po/od 8am
Tab shelcal 500mg po/od
Tab sodium bicarbonate 500mg po/bd
Tab nicardia 20mg po/tid
Probiotics
She’s not a known case of diabetes, hypertension, CAD, asthma, tuberculosis.
Personal history:
Appetite :lost
Diet: vegetarian
Bowels : loose stools since 3 days
Micturition: normal
No addictions
General examination:
Pallor: present
No icterus, cyanosis, clubbing, lymphadenopathy, oedema of foot.
Vitals:
Temperature: 98.2 F
Pulse rate: 131bpm
Respiratory rate: 24/min
BP: 180/110mmhg
Spo2: 98%
GRBS: 98mg/dl
Systemic examination
CVS:
S1 ,S2 present
No murmurs
Respiratory system:
Bilateral air entry present
Normal vesicular breath sounds heard
No dyspnoea and no wheeze
Per abdomen:
Shape of abdomen: scaphoid
Tenderness present around umbilicus
Liver and spleen are not palpable
CNS:
Patient is conscious
Speech: normal
Cranial nerves: normal
Motor and sensory system: normal
Glassgow coma scale: E4 V5 M6
Provisional diagnosis: ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE SECONDARY TO ACUTE GASTROENTERITIS WITH HYPERKALEMIA WITH ANAEMIA WITH THROMBOCYTOPENIA.
Known case of SLE WITH LUPUS NEPHRITIS class 4/5.
Known case of HTN since 3 months.
Investigations:
Hemogram:
Hb: 4.4
Total count: 5,500
PCV: 13.6
RBC:1.59
Platelet count:90,000
Peripheral smear:
Anisopoikilocytosis with predominantly normocytic seen with few microcytes and few pencil forms.
WBC: with in normal limits
Platelets: count reduced on smear
Hemoparasites: no hemoparasites seen
Impression: normocytic, normochromic anemia with thrombocytopenia.
Serum electrolytes:
Sodium: 138
Potassium:5.9
Chloride:108
Calcium ionized:1.14
Serum creatinine: 7.2
Blood urea: 154
LFT:
Total bilirubin: 0.38
Direct bilirubin: 0.17
SGOT:13
SGPT:12
ALP: 89
Total proteins: 5.5
Albumin: 3.0
A/G ratio: 1.24
RBS:85
Serum electrolytes on 7/2/23
Sodium: 137
Potassium:5.3
Chloride:103
Calcium ionized: 1.11
you
APTT: 31 sec
PT:15 sec
INR: 1.11
Stool for occult blood: positive
Usg abdomen:
B/L raised echogenecity in both kidneys
Mild ascites
Treatment:
IV FLUIDS NS @100 ml/hr
Nebulisation with duolin 6th hourly
Inj PAN 40 mg IV/OD
Inj ZOFER 4mg IV/SOS
Inj LASIX 40 mg IV/BD
Inj METROGYL 500 mg IV/TID ( day2)
Inj METHYLPREDNISOLONE 1gm IV/OD (Day1)
Tab SPORLAC DS PO/BD
This patient got admitted in our hospital 3 months ago and here’s the link of my co intern Dr.Rishitha reddy’s blog
https://rishithareddy30.blogspot.com/2022/11/30-yrs-old-female.html
Comments
Post a Comment