50 years old female with fever and chills following Day care dialysis(MHD)
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 comment
CHIEF COMPLAINTS:
A 50 year old female came to Medicine department with cheif complaints of Pedal edema;Shortness of breath and decreased urine output.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 8 months back
Important clinical features -
After 1 hour of start of dialysis she developed High grade fever; with chills ;shortness of breath;low back pain and neck pain.
She had 1 episode of vomiting ; non projectile ;non bilious ; food particles as content.
Same day evening developed signs of dehydration.
Next day had nausea;generalised weakness and Low grade fever.
No History of cough;burning micturition;abdominal pain.
PAST HISTORY :
No similar complaints in the past.
History of Hypertension since 3 years
History of Diabetes since 15 years
No history of tuberculosis;Epilepsy;Coronary Artery Disease.
PERSONAL HISTORY:
She wakes up early at around 5 :30 am and goes for agricultural work and has tea at around 8 :00am and again goes for work in field and around 12 :00pm she has her lunch and takes rest for sometime and again she's does work in field upto 5 pm and goes to home and does home work and sleep at around 9 :30 pm
This daily routine of her has been disturbed since 8 months
She takes Mixed diet
Appetite is normal
Sleep adequate
Bowel and bladder normal
No addictions
FAMILY HISTORY:
None of her family members suffered from this problem.
ALLERGIC HISTORY:
No known allergies to any drugs or food
GENERAL PHYSICAL EXAMINATION:
Patient is Conscious;Coherent and Cooperative
Well oriented to time place and person
Fever chart:
Vitals
Monitoring vitals
1/11/22 to 4/11/22
Pallor-
Icterus - Absent
No Clubbing;cyanosis ;
Edema:
On hand
Pedal edema
SYSTEMIC EXAMINATION:
ABDOMEN EXAMINATION:
INSPECTION:
Shape of abdomen- distended
Engorged veins -Absent
PALPATION:
No local rise of temperature
No Epigastric tenderness
No palpable mases
No hepatomegaly
No splenomegaly
PERCUSSION:
normal liver span
ASCULTATION :
bowel sounds heard
Respiratory system;
-Shape of the chest normal,
-Trachea appears to be in centre
-Normal vesicular breath sounds heard
Cardiovascular system;
- S1 S2 heard
- No murmors
CNS EXAMINATION :
- patient is conscious
- Normal
Investigations :
Chest Xray -
Microbiological evidence of E.coli
ECG
26/11
28/11
Interpretation of Hb;TLC;Platelet count;urea;creatine
27-11-22 to 4-11-22
Interpretation of sodium;potassium;chloride ions
27-11-22 to 4-11-22
Reports of 18-11-22
PROVISIONAL DIAGNOSIS:
CKD secondary to Diabetic nephropathy
With sepsis.
And
Herpes labialis.
Treatment
ICU care:
Inj.Zofer
Inj.Piptaz
Tab.Sporlac
Tab.ultracet
Tab.paracetomol
Inj.Pantop
Tab .nodosis
Inj.lasix
Inj.Neomol
Tab.Orofer
Tab.Shelcal
Inj.optineurin
Candid oral paint
Inj.HAI
https://www.ncbi.nlm.nih.gov/books/NBK536920/
Comments
Post a Comment