general medicine case 7

 Anahita behara 

roll no 08

This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.


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 45 year old female had come to the OPD with complaints of burning micturition, fever and pain in the loin (right side) since one week

CHIEF COMPLAINT 

-burning micturition since one week 

-fever and right-sided loin pain since 1 week 

HISTORY OF PRESENT ILLNESS

The patient was apparently asymptomatic a week ago , She had received symptomatic treatment in another hospital for her symptoms (as mentioned in the chief complaint ) , however she was referred to KIMS narkatpalli as her platelet count was low.

her fever was intermittent and low grade  

she developed nausea and shortness of breath (grade 2-3 ) yesterday (19th august 2021)

HISTORY OF PAST ILLNESS 

k/c/o Hypertension since 14 years , she has been taking Amlong-AT 5/50mg since 1 year 

n/k/c/o diabetes mellitus , thyroid disease , tuberculosis 

TREATMENT HISTORY 

Amlong TABLET 5/50mg since 1 year 

PERSONAL HISTORY 

-age : 45 

-marital status : married 

-occupation : labourer

-appetite : normal , non- vegetarian

-bowel movement : regular

-micturition : burning micturition 

 -no known allergies 

-addictions : she has been taking alcohol occasionally since the past 20 years 

FAMILY HISTORY 

not relevant 

GENERAL EXAMINATION 

-pallor ; Not present 

-icterus ; not present 

-cyanosis; not present 

-clubbing ; not present 

-lymphadenopathy ; not present 

-pedal oedema ; not present 

-malnutrition ; not present  

-dehydration ; mild 

-temperature ; 98.6 

-pulse rate ; 86/min

-respiratory count ; 18/min

-BP ; 100/70

-SPO2 at room air ; 92 % 

SYSTEMIC EXAMINATION 

CVS 

-normal S1 and S2 heard

RESPIRATORY SYSTEM 

-no dyspnoea

-wheeze is present 

-vesicular breath sounds 

-position of trachea : central

ABDOMEN

-shape of abdomen : obese

-tenderness : diffuse , over right sided loin at the renal angle 

CNS 

-conscious and coherent 

OBSTRETIC HISTORY 

age at marriage : 16

para : 2

living children : 2 

obstretic formula : G2P2 


BIOCHEMICAL INVESTIGATIONS 

serum electrolytes on 24/08/2021

serum creatinine on 24/08/2021


blood urea on 24/08/2021


random blood sugar on 24/08/2021

complete urine examination done on 24/08/2021



liver function test done on 24/08/2021







                                                              hemogram done on 24/08/2021


                                                                         




DIAGANOSTIC IMAGES 

                                                         ultrasound report


ECG report
                                                                         

chest X-ray
                                                                                         

X-ray of abdomen

                                                                                

urinanalysis test strip results

presence of proteins


specific gravity


https://www.siemens-healthineers.com/en-us/urinalysis-products/urinalysis-reagents/multistix-10-sg-reagent-strips


MICROSCOPIC FINDINGS



RBC : normochromic and normocytic 

WBC : normocytic 
Platelet count : reduced on smear -  indicative of thrombocytopenia

  -PROVISIONAL DIAGNOSIS   
      
dengue ; thrombocytopenia 
right pyelonephritis?


  -TREATMENT PLAN



 this is an ongoing case and details will be updated

this elog was compiled with the guidance of Dr.Achal (2016)













 

















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