Name: K.Sannith Reddy
Roll no. 65
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 :
COMPLAINTS AND DURATION
A 70year female house wife by occupation brought to the Casuality
c/o fever since 4 days
slurring of Speech since 4 days.
SOB since 4 days
B/L pedal edema since 4days
Left upper limb and lower limb weakness since 10years
HISTORY OF PRESENT ILLNESS :
Patent was apparantly asymptomatic 4 days back then she developed fever low grade associated with chills and rigor Assosiated with shortness of breath grade 2 & associated with slurring of Speech and b/l pedal edema pitting type
weakness of left upper limb and lower limb from 10years
For fever they took treatment at local Rmp
HISTORY OF PAST ILLNESS
Is k/c/o HTN since 10 years on telma 40mg
IS N/K/C/O DM/ASTHMA/CAD/EPILEPSY
underwent craniotomy 10 years back at gandhi hospital for cerebral hemorrhage where she was diagnosed to have hypertension and started on medication
H/o NSAID Abuse
PERSONAL HISTORY:
Diet - mixed
Appetite- normal
Bowel and bladder movements regular
sleep- adequate
Addictions:
Alcohol (toddy) consumption occasional once in 6 months
DRUG HISTORY :
On telma 40 medication since 10 years for hypertension.
SURGICAL HISTORY:
Underwent craniotomy for cerebral hemorrhage 10 years back in Gandhi hospital
From then pt had weakness in left upperlimb and lower limb
GENERAL EXAMINATION:
Pt is c/c/c
No ,icterus,cyanosis, clubbing, lymphadenopathy
Pallor present
edema present (pitting type)
vitals:
temp - 99°F
pr: 102bpm,bp: 100/80 mm hg
rr:16cpm spo2 95% at ra
grbs- 160mg%
SYSYTEMIC EXAMINATION:
CVS: S1, S2 heard no murmurs
RS: BAE presnt ,NVBS heard
P/A: distended ,non tender
CNS:
pupils -B/L NSRL
Tone:
Normal in both upper limb and lower limb on right side but decreased on left side
POWER :
Right side: UL 4/5,LL 4/5
Left side: UL 3/5 ,LL 3/5
REFLEXES:
B T. S. K. A. PLANTAR
RIG ++. ++. +. ++. +.
LEFT. ++. ++ +. ++. +.
INVESTIGATIONS:
ECG:
29/1/23
28/1/23
NCCT KUB:
2D ECHO:
USG ABDOMEN AND PELVIS:
XRAY CHEST:
ABG:
28/1/23
29/1/23
30/1/23:
31/1/23:
BLOOD C/S : E.COLI WAS ISOLATED
URINE C/S : NO GROWTH FOUND
PROVISIONAL DIAGNOSIS:
SEPSIS WITH AKI (RESOLVING)
?EARLY EMPHYSEMATOUS PYELONEPHRITIS WITH RIGHT RENAL CALCULI WITHODERATE RIGHT HYDROURETERONEPHROSIS
K/C/O HTN since 10 years
TREATMENT GIVEN:
On28/1/23
) IVF RL and NS @100ml/hr
2)INJ PIPTAZ 2:25 mg IV/TID
3)INJ NEOMOL 1GM IV IF TEMP > 100F
4)INJ PAN 40MG IV/OD
5)INJ ZOFER 4mg IV SOS
6)INJ OPTINEURON 1 AMP IN 100ml NS IV OD
7)T Dolo 650MG PO sos
8)T NODOSIS 500MG PO BD
9)T ECOSPRIN- AV 75/10 mg PO OD
10) T NICARDIA 10MG PO SOS
On 1/2/23
S
chills present at night but no fever spikes
O
Pt is c/c/c
Temp 98.6°F°F
pr -90bpm
Bp: 100/70mmHg
spo2 98% on ra
grbs- 98mg/dl
i/o 2300/1150
CVS : s1,s2 herad
RS: BAE +
CNS: NFND
p/A : soft ,NT
Hb: 12.1---10.3---9.7---10---9.3
TC- 25.9k----17.1k---10.5k---11.6k---23.4k(raised)
RBC -4.23---3.64---3.4---3.52---3.2
PLT- 1.2L---65000---1L---1.43L---1.94L
SERUM ELECTROLYTES:
Na+ 137---138---136---137---136
k+. 5.6---4.5---4.9---5.1---5.3
Cl-114---102---104---104---10
A
SEPSIS WITH AKI (RESOLVING)
?EARLY EMPHYSEMATOUS PYELONEPHRITIS WITH RIGHT RENAL CALCULI WITHODERATE RIGHT HYDROURETERONEPHROSIS
K/C/O HTN since 10 years
P
1) IVF 2unit NS @75ml/hr
2)INJ PIPTAZ 2:25 mg IV/QID STOPPED AFTER GIVING FOR FOUR DAYS AS COUNTS ARE INCREASING AND STARTED ON INJ MEROPENEM
3)INJ NEOMOL 1GM IV IF TEMP > 100F
4)INJ PAN 40MG IV/OD
5)INJ ZOFER 4mg IV SOS
6)INJ OPTINEURON 1 AMP IN 100ml NS IV OD
7)T Dolo 650MG PO sos
8)T NODOSIS 500MG PO BD
9)T ECOSPRIN- AV 75/10 mg PO OD
10)T CLINIDIPINE 10MG PO/BD
11)SYP CREMAFIN 15ML PO/HS
12)OINT THROMBOPHOBE FOR L/A
13)PROTEIN XPOWDER 1 SCOOP IN 100ml milk PO/TID
14) NEBULIZATION WITH DUOLIN 8TH HOURLY
15)MONITOR VITALS 2ND HOURLY
16) STRICT I/O CHARTING
WAITING FOR BLOOD C/S REPORTS
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