GENERAL MEDICINE CASES
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've 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.
13Y/F presented to the opd with chief complaints of
1) fever since 36 days
2) red coloured urine since 33 days
3) pedal edema since 30 days
HOPI:
Patient was apparently asymptomatic 36 days ago , then developed fever which was low grade, intermittent type, relieved with medication not associated with chills & rigors . Vomitings 4 episodes /day for 3 days , content food particles, non bilious, non projectile. Loose stools 3-4 episodes/day, watery , not associated with abdominal pain, blood in stools .
Patient presented to the opd with complaints of hematuria since 33 days whole stream of urine red in colour. No burning micturition and frothiness of urine
Then patient developed generalised swelling of body ,initially both lower limbs pedal edema then abdominal distension and facial puffiness.No h/o sore throat , decreased urinary output.
PAST HISTORY:
No history of similar complaints in the past
CARDIOVASCULAR SYSTEM:
on inspection : chest is elliptical bilaterally symmetrical
Palpation: apex beat felt
All inspectory findings confirmed
RESPIRATORY SYSTEM:
Inspection:
Shape- elliptical
B/L symmetrical ,
Both sides moving equally with respiration .
No scars, sinuses, engorged veins, pulsations
Palpation:
Trachea - central
Expansion of chest is symmetrical.
Vocal fremitus - normal
Percussion: resonant bilaterally
Auscultation:
bilateral air entry present. Normal vesicular breath sounds heard.
CENTRAL NERVOUS SYSTEM:
Conscious,coherent and cooperative
Speech- normal
No signs of meningeal irritation.
Cranial nerves- intact
Sensory system- normal
Motor system:
Tone- normal
Power- bilaterally 5/5
Reflexes -
Triceps +2 +2
Biceps. + 2 +2
Supinator +2 +2
Knee +2 +2
Ankle +2 +2
PROVISIONAL DIAGNOSIS:
POST INFECTIOUS GLOMERULONEPHRITIS ?SECONDARY TO ECOLI/SALMONELLA/STREPTOCOCCI
INVESTIGATIONS :
Fever chart :
TREATMENT:
17/12/22
SALT AND FLUID RESTRICTION
Vitals monitoring 4th Hrly
18/12/22
13 year old girl, high school student came to the OPD with history of fever 36 days ago high grade, continuous type relieved with medication. Vomitings 4 episodes /day, content food particles, non bilious, non projectile. Loose stools 3-4 episodes/day, watery .
No presented with the complains of hematuria since 33 days, gross hematuria whole stream of urine.Both lower limb pedal edema since 30 days, pitting type.
No history of sore throat, decreased urine output .
S
C/o generalised swelling of body
O
Pt is C/C/C
BP:120/90mmHg
PR:74bpm
RR:18cpm
SpO2:98% on RA
Temp :afebrile
CVS:S1S2 +
RS :BAE +
PA-soft no organomegaly
A
POST INFECTIOUS GLOMERULONEPHRITIS SECONDARY TO ECOLI/SALMONELLA/STREPTOCOCCI
P
SALT AND FLUID RESTRICTION
Vitals monitoring 4th Hrly
19/12/22
13 year old girl, high school student came to the OPD with history of fever 36 days ago high grade, continuous type relieved with medication. Vomitings 4 episodes /day, content food particles, non bilious, non projectile. Loose stools 3-4 episodes/day, watery .
No presented with the complains of hematuria since 33 days, gross hematuria whole stream of urine.Both lower limb pedal edema since 30 days, pitting type.
No history of sore throat, decreased urine output .
S
C/o generalised swelling of body
O
Pt is C/C/C
BP:110/70mmHg
PR:80bpm
SpO2:98% on RA
Temp :afebrile
CVS:S1S2 +
RS :BAE +
PA-soft no organomegaly
A
POST INFECTIOUS GLOMERULONEPHRITIS ? SECONDARY TO SALMONELLA/STREPTOCOCCI/ECOLI
P
SALT AND FLUID RESTRICTION
TAB LASIX 40mg PO/BD
Plan for renal biopsy
20/12/22
13 year old girl, high school student came to the OPD with history of fever 36 days ago high grade, continuous type relieved with medication. Vomitings 4 episodes /day, content food particles, non bilious, non projectile. Loose stools 3-4 episodes/day, watery .
No presented with the complains of hematuria since 33 days, gross hematuria whole stream of urine.Both lower limb pedal edema since 30 days, pitting type.
No history of sore throat, decreased urine output .
S
C/o b/l lower limbs
No shortness of breath
O
Pt is C/C/C
BP:100/80mmHg
PR:72bpm
SpO2:98% on RA
Temp :afebrile
CVS:S1S2 +
RS :BAE +
PA-soft no organomegaly
A
POST INFECTIOUS GLOMERULONEPHRITIS ? SECONDARY TO SALMONELLA/STREPTOCOCCI/ECOLI
ANEMIA OF CHRONIC INFLAMMATION
P
SALT AND FLUID RESTRICTION
TAB LASIX 40mg PO/BD
Vitals monitoring 4th Hrly
Plan for renal biopsy today
21/12/22
13 year old girl, high school student came to the OPD with history of fever 36 days ago high grade, continuous type relieved with medication. Vomitings 4 episodes /day, content food particles, non bilious, non projectile. Loose stools 3-4 episodes/day, watery .
No presented with the complains of hematuria since 33 days, gross hematuria whole stream of urine.Both lower limb pedal edema since 30 days, pitting type.
No history of sore throat, decreased urine output .
S
C/o b/l lower limbs
No shortness of breath
O
Pt is C/C/C
BP:110/80mmHg
PR:72bpm
SpO2:98% on RA
Temp :afebrile
CVS:S1S2 +
RS :BAE +
PA-soft no organomegaly
A
POST INFECTIOUS GLOMERULONEPHRITIS
ANEMIA OF CHRONIC INFLAMMATION
P
SALT AND FLUID RESTRICTION
TAB LASIX 40mg PO/BD
Vitals monitoring 4th Hrly
Plan for renal biopsy today
