Case history 1
A 65 year old woman with vomiting, stomach ache since 20 days.
General Medicine Case 1;
August 16 2021.
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Date of Admission:31/07/2021
A 65 year old woman presented to the hospital with the complaints of-
• vomiting
• stomach ache
-since 20 days
HISTORY OF PRESENT ILLNESS.
A 65 year old married woman and a mother of 4, who was an occasional alcoholic, who was a homemaker, was apparently asymptomatic before 20 days. Her daily routine included waking up at 6am, cooking food for her family, separating rice grains from rice chaff, having food and sleeping in the afternoons. Whenever she could afford, she used have alcohol. 20 days back, there was a suddenly onset of stomach pain and vomiting. The vomiting was not projectile in nature, based on the information provided by the patient. This caused her great distress and considerably decreased her appetite. She went to a hospital in Nalgonda few days back. She was referred to Kamineni and has been admitted here for 11 days.
PAST HISTORY
• The patient underwent no surgeries in the past.
• There is no history of Tuberculosis, Diabetes Mellitus, Hypertension, Epilepsy, Asthma.
• The patient was never a victim of any kinds of accidents.
• In the span of 11 days at the hospital, she underwent dialysis thrice.
• The patient was also diagnosed to be anemic.
• Blood transfusion was done once at the hospital.
DRUG HISTORY
• Patient was not on any kinds of drugs prior to coming to the hospital.
• On equiry, the patient refused to have taken any sorts of steroids, insulin, antihypertensives, diuretics, ergot derivatives, monoamine oxidase inhibitors, hormone replacement therapy or contraceptive pills — prior to coming to the hospital.
ALLERGY HISTORY
• Patient is not allergic to any known drug or food.
• There is no known allergy to dust or pollen in the patient.
PERSONAL HISTORY
• Patient is of mixed diet. But she has been an obligatory vegetarian since the onset of her stomach pain.
• She looks slightly malnourished.
• Her appetite DECREASED since she was presented with stomach pain.
• Her bladder function is good.
• Patient has been suffering from constipation since a long time before the presentation of the illness.
• Her sleep has been disturbed since the onset of her pain.
• She is a known smoker.
• Patient is an occasional drinker. (1 or 2 times a month.)
• She has 4 kids, all delivered vaginally.
• She has attained menopause.
FAMILY HISTORY
• There is no case of such illness seen in her family members.
• There is no history of cancer present in the patient.
• All the deaths in her family have been natural.
GENERAL SURVEY
• The patient is concious, coherent and cooperative.
• On examination, patient appears to be a little fatigued.
• Patient appears to be semi-conscious but responsive and attentive on command.
• Her attitude is good.
• Her build is ectomorphic.
• There are no characteristic facies.
• No decubitus is present.
• Patient has substantial pallor.
• Patient appears to be mildly dehydrated.
• Patient had itch marks all over her body suggesting pleuritis.
• Vitals (on examining)
Temperature- 98.3°F
Pulse Rate- 92
S1 and S2 are heard.
Breathing sounds are normal.
Blood Pressure is 100/60.
PROVISIONAL DIAGNOSIS
Acute Renal Failure.
INVESTIGATIONS
1) ECG
2) ULTRASOUND REPORT (No ultrasound picture was found in pt files.)
3) ABG
4) Hemogram
5) CUE
6) RFT
7) Serum Electrolytes (Na, K, Cl)
8) Serum Creatinine
9) Blood Urea
10) Bacterial Culture and Sensitivity Report
CLINICAL DIAGNOSIS
Acute Renal Failure secondary to Urosepsis.
TREATMENT
0.9% NaCl @ 200ml /1 hour
INJ Ceftriaxone 1g IV/BD
INJ Pantop 40mg IV/OD
INJ Tramadol 1AMP in 100ml normal saline IV/ SOS
INJ Erythropoietin 4000IU S/C Weekly twice.
TAB Orofer XT PO/ BD
TAB Nodosis 500 PO/ TD.
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