General medicine

LEARNER REPORT
"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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comments box.


60Y/F WITH C/O RETENTION OF URINE:
march 8th, 2022.

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.

A 60yr old dailywage labourer came to casuality with complaints of rentention of urine since 4days

HISTORY OF PRESENTING ILLNESS

pt was apparently asymptomatic 15 days back.Then she developed fever 15 days back , low grade with chills and rigor.
It is not associated with profuse sweating on and off, increased during night. She also complains of cold which is not associated with cough which lasted for 10 days and relieved on medication . She also complains of suprapubic tenderness and bulge is noted 3 days back 
She went to local hospital for examination , foley's was passed ( approx 1 lit of urine was passed ) 
No C/O of chest pain , palpitations and syncopial attacks 

PAST HISTORY
N/k/c/o HTN , DM , Thyroid , TB 

PERSONAL HISTORY:
She follows a mixed diet. 
Appetite -Normal,
Bladder movements- abnormal 
Bowel movements- Normal . 
Sleep- Adequate.

FAMILY HISTORY: No significant family history.
DRUG HISTORY: No known drug allegies

General examination : patient is conscious ,coherrent, co operative and well oriented to her surroundings.she is moderately built and nourished.no pallor ,no cyanosis, no icterus, no lymphadenopathy. 

Vitals:. Temperature: afebrile. 
Pulse rate: 98 beats / min.
 Respiratory rate: 19 cycles / min.
 Bp: 110/70 , 
Spo2: 99 
Grbs: 112mg/dl

SYSTEMIC EXAMINATION:
CVS: S1S2 heard, no murmurs
RS: BAE+ NVBS+
P/A: Soft, Non-tender
CNS: NAD

Investigations:(4/3/22)




Investigations:                    
              Date-    4/3  | 5/3  |  6/3  |  7/3  |  8/3  |  9/3 |
S. creatinine-     9.1      6.1      5.3       3        2.2      1.8
Blood urea-        333   260     200    160     100      64
Hb%-                   9.2     9.8       10.6     9.4      9.8       8.9
TLC-             24500, 19000, 17400,13100,12700,11000
Platelet.c-    30000,48000,70000,   1.1,      1.5       1.8 


Provisional diagnosis: ACUTE KIDNEY INJURY 2° TO UROSEPSIS.

TREATMENT:
1.Inj.Piptaz 4.5gm/iv/stat 
Foll by 2.25gm iv/stat
2.inj.PAN 40MG/IV/OD
3.INJ.ZOFER 4MG/IV/STAT
4.IVF - NS AND RL @100ML / HR
5.INJ.OPTINEURON 1AMP/HR 500ML NS/IV/OD
6.TAB.NODOSIS 500MG OD
7INJ.LASIX 40MG/IV/TID..

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