65 year old female presenting with fever ,nausea ,vomiting ,de novo hypertension ( recently diagnosed)

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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 diagnosis and treatment plan. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

CHIEF COMPLAINTS :

1) c/o fever since 10 days associated with chills and rigors

2) burning micturition

2) c/o nausea and vomitings since 5 days

3) c/o giddiness since 5 days

History was taked from her attender who is a reliable source

HISTORY OF HER PRESENTING ILLNESS : 

Patient was apparently normal 30 years ago then developed multiple recurrent episodes of shortness of breath during the  winter season ,these episodes are  not associated with cough, sputum, and  subside after taking medication

 ( Antihistamine??) . This affects her every year .

    Patient   then she developed  neck pain, back ache and and bilateral knee joint pains  3- 4years ago for which she is taking ayurvedic medicine and pain killers, monthly 15 to 20 times ( 1-2 tablets a day).

 Since the past 1 month she was experiencing generalised weakness and generalised body pains.

Then she developed low grade fever of intermittent type associated since 10 days along with burning micturition thereafter she developed  nausea and vomiting since 5 days which lead her to become lethargic and weak then she was taken to a local RMP where she was treated with saline infusion and paracetamol then she was referred to a higher centre for testing where she was diagnosed with hypertension and then was referred to our hospital on suspicion of kidney disease.

DAILY ROUTINE: patient wakes up at around 6 in the morning and then proceeds to the stables where she feed her cows then she returns home and spend the rest of the day often watching tv and sleeping or taking here of her grandkids. The patient does not have a strenuous home life as most of the household work is taken care by her sons and daughter in law's.

COURSE OF RECENT EVENTS

PAST HISTORY:

HTN was diagnosed 5 DAYS back and she is on TELMIKIND PO OD.

N/K/C/O DM, TB , EPILEPSY

NO H/O PAST SURGERIES

FAMILY HISTORY:

No similar complaints in family 

PERSONAL HISTORY: 

  APPETITE : decreased since 10 days

  DIET: mixed 

  SLEEP : disturbed

  BOWEL AND BLADDER : regular

  MICTURITION : decreased 

DRUG HISTORY :

 Use of some unknown medication which helped in relieving her shortness of breath which occurs every winter ( Antihistamines??)

Use of painkillers since 3-4 years taking about 15 to 20 tablets for her neck ache , back ache and b/l knee pain 

 Tablet used is unknown 

She also took some ayurvedic medicine along the course during same duration along with with painkillers.

 GENERAL EXAMINATION:

She concious coherent and cooperative

Pallor - present 

Icterus - absent

Cyanosis - absent

Clubbing- absent

Genralised lymphadepathy- absent

Pedal edema - none

     VITALS 

TEMP : 98.6 ⁰C

BP : 140/80 mm hg

RR : 20 cpm post extubation

PR : 108 bpm

SYSTEMIC EXAMINATION 

Cardiovascular system

s1 and s2 heard ,no murmurs 

Respiratory system

Central position of trachea 

Bilateral air entry present 

Vesicular breath sounds

No wheeze,no dyspnea

Abdomen

Scaphoid shape

Slight tenderness 

No bowel sounds

INVESTIGATIONS

 Usg findings: 

USG ABDOMEN :

FINDINGS :-  

 1) Renal calculi ( 10mm) at right PUJ ( pelvico - ureteric junction )

 2) Renal calculi (10mm) at mid pole of right kidney

INTERPRETATION : -

1) Right renal calculi at PUJ causing hydronephrosis of the same kidney.

2) mild hydronephrosis noted in the left kidney.

Differential diagnoses:

1) acute glomerulonephritis

2) acute kidney injury

3) infection of the renal caliculi along with hydronephrosis

TREATMENT 

28/11/22

 Inj. Human actrapid Insulin -- > 10 units

 

29/11/22

Lasix ---> 40mg PO BD

Orofer---> PO OD × 7 days

Shelcal ---> 500 mg PO OD

Paracetamol ---> 650 mg PO SOS

ZOFER ---> 4mg IV stat

30/11/22

Dialysis ( 29/11/22):- during which she experienced a seizure (around 11pm [29th]-12 am[30/11])episode which was controlled by

    LEVIPIL ---> 1g IV stat

    OPTINEURIN 1g IV stat

Then she was intubated 

  Given

  Inj. ATRACURIUM 

  Inj. DEXAMETHASONE

Inj. LEVIPIL ---> 500mg IV TID

Inj. MONOCEF---> 1gm IV BD

Tab LASIX---> 40 mg PO OD

Tab OROFER---> PO OD

Tab SHELCAL---> 500mg PO OD

Tab paracetamol ---> 650mg PO SOS

Inj. OPTINEURIN

Inj. PAN ---> 40 mg IV OD