A 66 year old female with pain in the abdomen

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.    


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 diagnosis and treatment plan 


A 66 year old female came to the opd with chief complaints of pain the lower left abdomen since 5 days ,decreased urine output since 5 days and vomiting since 4 days.

History of presenting illness: patient was apparently asymptomatic 5 days then she developed pain in the left lumbar region which was sudden, dragging type, continuous radiating to the pelvic region and temporary got relieved on medication, was associated with vomiting 4 days back which was non bilious and non projectile type 5-6 episodes a day.she also complained of decreased urine output.

No h/o fever

Noh/o itching

No h/o nausea

No h/o cough, difficulty in breathing

No h/o chest tightness, palpitations


Past history:

K/c/o HTN since 6 years

K/c/o DM since 10 years

Not a k/c/o CVD,TB, asthma, epilepsy.

Family history: no significance

Personal history:

Diet: mixed

Appetite:normal

Sleep: inadequate since 5 days

Bowel: irregular since 5 days

Tobbaco chewing additions for 30 years

No allergies 

Drug history: on Tab. telmisartan since 8 years


General examination : patient was conscious coherent cooperative and was moderately built and nourished

Pallor: present

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy:absent

Pedal edema: present(bilateral)



Vitals:

Temperature - afebrile

PR :- 88bpm

BP :- 130/80 mm Hg

RR:- 20cpm

Systemic examination:

CVS:thrills: No

S1,S2 heard,no murmurs

Respiratory system:

Trachea: Central

Breadth sounds: heard

No additional sounds

Abdomen examination:

Shape of the abdomen: distended

Stretch marks present

No scars,no engorged veins

Umbilicus : inverterd

Hernial orifices: normal

Palpation:

Tenderness: present on left lumbar region

Palpable mass: absent

Liver not palpable 

Tenderness present on left lumbar region

Spleen not palpable 

BOWEL SOUNDS HEARD

CNS : normal

Provisional diagnosis:

AKI secondary to obstructive uropathy


Investigations:

Blood urea:150 mg/dl

Serum creatinine:8.7 mg/dl

Haemoglobin:7.4gm/dl

RBC count:2.5 millions

Treatment:

Tab.CLNOD 10 mg

Inj.lasix 40mg

Inj.buscopan

Ivf.NS




Comments

Post a Comment

Popular posts from this blog

55 year old male with SOB

Image
  GENERAL MEDICINE  THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT . 55 YEAR OLD MALE PATIENT WITH SHORTNESS OF BREATH AND PEDAL EDEMA Case details: 55 year old male,driver by occupation, came to the OPD with the chief complaints of Shortness of breath and pedal edema since 4 days, low grade fever and dry cough since 2 days. History of presenting illness  -  Patient was apparently asymptomatic 1month ago, then he developed  1)shortness of breath which is incidious, gradually progressive, NYHA grade 2, aggravated on exertion and relieved with rest. 2)Bilateral pitting type of pedal edema extending upto ankles,aggravated on walking, relieved on lying down. His
Read more

A 60 year old male with chief complaints of abdominal pain and distesioy

Image
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.     This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. 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 diagnosis and treatment plan  A 60 year old male resident of kodad labourer by occupation came with chief complaints of abdominal swelling since 3 months and abdominal pain since 3 months History of presenting illness: patient
Read more

55 year old female with chief Complaints of fever

 This is an online E-log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through a series of inputs available global online community of experts with the aim to solve the patient’s clinical problems with the collective current best evidence based inputs. This E log reflects my patient centred online learning portfolio and your valuable inputs in the comments section. A 55 yr old female who is a home maker came to opd with c/o fever since 4 days.  Patient was apparently asymptomatic 4 days back then she developed fever which was high grade and continuous type, didn't releive on medication.  H/o 1 episode of vomiting 4 days back contents being food particles, non bilious, non projectile.   H/o giddiness & fall 3 days ago.   No c/o SOB, pedal edema  No c/o melena, hemetemesis  K/c/o HTN since 2 yrs on medication ( Tab,. ATENELOL 50mg PO / OD )  She went t
Read more