55 year female with pain abdomen, fever, bloody stools
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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.
Following is the view of the case
Case
A 55/ F who is a daily wage labor by occupation and a native of miriyalaguda came with the
chief complaints
. pain abdomen since 20 days
. fever since 20 days
. vomitings since 7 days
. burning micturition since 7 days
. bloody stools since 3 days
HOPI
Patient was apparently asymptomatic 4 months back then she pain abdomen(lower) which is non radiating colicky type associated with nausea, vomiting and was taken to a local doctor and was diagnosed as ? abscess.
Since 20 days she again c/o pain abdomen- colicky type, non radiating, associated with nausea, vomiting aggravated on taking food.
Fever since 20 days high grade on and off associated with chills and rigor subsided on medication.
C/O burning micturition since7 days and history of recurrent UTI.
Patient also complaints of hard bloody stools since 3 days.
Past history
K/C/O type 2 DM since 13 days and is on tablet glime M1 PO/OD.
3 years back she was diagnosed as hypertensive by a local RMP and was prescribed medication but she didn't take medication.
Not a known case of TB, asthma , epilepsy
She has a H/O dental infection for which 5 of her teeth were removed.
She has a H/O diminution of vision 6 months back.
Personal history
Diet; mixed
Appetite; decreased
Sleep; adequate
Bowel; irregular
Bladder; burning micturition
Addictions; none
Allergies; none
Menstrual history
Patient is nulliparous.
she was treated for infertility incompletely.
She attained menopause 2 years back.
General examination
Patient is conscious , coherent, cooperative well oriented to time, place and person.
she is moderately built and nourished.
There is no pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.
VITALS;
Temperature; 99F
PR; 86
RR; 18
Spo2; 87%
Grbs; 365
Systemic examination
CVS; S1, S2 heard
RS; BAE+, NVBS Heard
P/A ; Scaphoid abdomen, tenderness present in right iliac fossa, no palpable mass, bowel sounds heard.
CNS; No FND
Investigations
CBP;
Hb; 10gm/dl
Tc; 15300cells/cumm
Neutrophils; 88
Lymphocytes; 07
Eosinophils; 02
Monocytes; 03
Basophils; 00
Platelet count; 3.25lakhs/cumm
Smear; Microcytic hypochromic anemia with neutrophilic leucocytosis.
LFT;
Total bilirubin; 0.70mg/dl
Direct bilirubin; 0.24mg/dl
SGOT(AST); 18IU/L
SGPT(ALT); 13IU/L
Alkaline phosphatase; 201IU/L
Total proteins; 5.6gm/dl
Albumin; 2.5gm/dl
A/G ratio; 0.84
BLOOD UREA;
208gm/dl
SERUM CREATININE;
4.5mg/dl
URINE SUGAR AND ALBUMIN;
Albumin; trace
Sugars; ++
URINE PROTEIN AND CREATININE
Protein; 12mg/dl
Creatinine; 42mg/dl
SERUM ELECTROLYTES
SERUM ELECTROLYTES
SODIUM; 138mEql/L
POTASSIUM; 4.2mEql/L
CHLORINE; 98mEql/L
FASTING BLOOD SUGAR
155mg/dl
POST LUNCH BLOOD SUGAR
339mg/dl
GLYCATED HAEMOGLOBIN
HbA1c; 7.4%
PH; 7.33
PCO2; 31.7
PO2; 50.5
HCO3; 16.3
ECG;
X-ray;
Liver; Normal
Gall bladder; distended, wall thickness- normal
Pancreas; head visualised, normal
Spleen; normal
Right kidney; altered echotexture 12.3x4.9cm
Left kidney; normal, 11.5x5.1cm
Bladder; empty
PROVISIONAL DIAGNOSIS;
? Pre renal AKI secondary to? recurrent UTI
?acute GE
with denovo DM2 Since 13 days
with H/O Iliac abscess 4 months back
TREATMENT;
Inj HAI s/c pre-meal/TID
Foley's catheterisation
IVF-NS @6.0+30ml/hr
Inj PANTOP 40mg/OD/W
Inj ZOFER 4mg/BD
ORS sachets 2 in 1lit water -200ml after each episode
Inj CEFTRIAXONE 1gm/BD
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