SHORT CASE:- Practical Final Examination (65 YEAR OLD FEMALE WITH DECREASED 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.

Hallticket Number:-1701006148

CASE PRESENTATION:-

A 65 year old female patient came with the 

*Chief complaints of:-

- Low back pain since 7 days

- Redued urine output since 7 days

-Shortness of breath since 7 days

*History Of present Illness:-

Patient was apparently asymptomatic 4 years back then she developed

•Joint pains for which she went to local hospital and used medications (NSAIDS)for pain.Since then, she takes the medications when the pain appears without any regualtion.

•Patient went to a hospital with low back pain 2 years back,which on investigations were told to have renal failure.Patient didn't take up the treatment and continued on NSAIDs when pain appears.

•Patient now presents with decreased urine output and low back pain which is insidious in onset and cramping type

•SOB which was grade 2 in nature.

•Complaints of fever of low grade, intermittent in nature and relieved on medication. It was associated with burning micturition.

•No history of chills and rigor and pedal edema.

*Past History:-

•Not a known case of DM, HTN, TB, Asthma and epilepsy.

•4 years back patient had hysterectomy for prolapsed uterus.

•Patient took NSAIDS for 4 years.

*Family History:-Not significant.

*Personal History:-

•Diet: Mixed diet.

•Sleep: Adequate.

•Bowel habits:regular

•Bladder habits:decreased urine output

•No allergies and addictions.

*General Physical Examination:-

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

•He is moderately built.

•Pallor:- Absent

•Icterus:-Absent

•Cyanosis:- Absent

•Clubbing :- Absent

•Lymphadenopathy:- Absent

•Edema:-Absent

*Vitals:-

••Patient is afebrile

••Pulse rate:-82 bpm

••Blood pressure:-130/80 mm of Hg

••Respirtaory rate:-28 cpm

••SpO2:-96% on Room temperature

••GRBS:-113mg%

*Clinical Images:-

*Systemic Examination:-

••Abdomen 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 and shifting dullness.

••Auscultation:-

•Bowel sounds are heard.

••Cardiovascular system Examination:-

••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:-Appears to be central

•Apical Impulse is not appreciated 

•Chest is moving normally with respiration.

•No dilated veins, scars, sinuses.

••Palpatioon:-

•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 interscapular were all RESONANT.

••Auscultation:-

•Normal vesicular breath sounds heard 

•No adventitious sounds heard.

••Central nervous system:-

•Higher Mental Functions:-

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

•All cranial nerves:-intact

•Motor system:-Intact

•Superficial reflexes and deep reflexes:-present and normal

•Gait:- normal

•No involuntary movements

•Sensory system:-All sensation(pain, touch, temperature, position, vibration sense)are well appreciated.

Provisional Diagnosis:- Acute kidney Injury on Chronic Kidney Disease

*Investigations:-

*Hemogram:-

*Complete Urine Examination:-

*Serum Creatinine:-

*Blood Urea:-

*Serum Electrolytes:-

*Serum Albumin:-

*Serum Iron:-

*Ultrasound Abdomen:-

1.Grade 1 RPD changes in right kidney

2.Grade 2 RPD changes in left kidney

*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