General medicine case Acute kidney injury 28-06-22

 GENERAL MEDICINE CASE (28-06-22)


Welcome and greetings to every one who are visiting my blog. This is A.Sai Tarun of 5th semester. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.

DATE OF ADMISSION - 23/06/22

CHIEF COMPLAINTS

-45yr old female came to OPD with chief complaints of vomitings ,nausea and epigastric burning sensation.

HISTORYOF PRESENT ILLNESS

-Pt was apparently normal 4yrs back then she developed burning micturition, pedal edema, right loin pain for which she visited  local hospital.

-she diagnosed with rght renal caliculus with pyelonephritis  then referred to nims and there she went rght nephrectomy.

-since 10 -15 days she has been suffering with nausea,vomitings and epigastric discomfort.

- 4 to 5 episodes of vomitings with small quantity of food particles as it’s contents.

-No blood in vomitings.

HISTORY OF PAST ILLNESS

-Right nephrectomy in 2018

TREATMENT HISTORY

Not a k/c/o DM,HTN

Not a k/c/o CAD,TB,asthma,chemo,radiation and blood transfusion.

PERSONAL HISTORY

Mixed diet

Appetite Lost

Sleep adequate

Bowel movements regular.

Micturition abnormal.

FAMILY HISTORY

Not significant 

PHYSICAL EXAMINATION

Temp- afebrile

BP-130/80 mm hg

Pulse rate-82/min

Respiratory rate-16/min

Spo2-98%

-No signs of pallor,cyanosis,lymphadenopathy,icterus.

-Oedema present

SYSTEMIC EXAMINATION 


CARDIOVASCULAR SYSTEM

•S1, S2 heard

•No murmurs

RESPIRATORY SYSTEM:

•NVBS heard

•Position of trachea - central

•Breath sounds - vesicular

ABDOMEN

•Shape - scaphoid

•No Tenderness

•No palpable mass

 -No fluid present.

-No palpable liver or spleen


CENTRAL NERVOUS SYSTEM:

•Intact

•No focal defect

•No abnormality detected

CEREBRAL SIGNS

• No finger nose incordination

•No knee heel incordination.


INVESTIGATIONS















PROVISIONAL DIAGNOSIS 

Acute kidney injury 






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