FINALS - LONG CASE

 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 available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

Date of Admission-9/02/2022

A 45year old female who is farm worker by

occupation presented to OPD with chief

complaints of pain in the loin region along with 

fever which is irregular type since 1 week and

decreased urine output and burning

 mictirition since 1 day. 

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 week

back and then she developed fever which is

irregular type and subsided on medication.

She's also suffering from lower back pain in the

loin which is non radiating and no aggrevating

or reliveing factors.

The patient also suffering from burning

micturation and unable to pass urine since 1 day 

for which she's on dialysis currently 

Pedal edema since 1 week. 

Yesterday suddenly she stopped talking and then

remained silent.

HISTORY OF PAST ILLNESS :

The patient was identified with the presence of renal stones

one month back.

She underwent hysterectomy 35 years back.

The patient is not a known case of 

DM/HTN/Asthma/CAD/CKD.

PERSONAL HISTORY:

Appetite : Normal.

Diet : Mixed.

Bowel and bladder movements : Regular

Menstrual history : Hysterectomy 10 yrs ago.

Addictions : Occassionally alcoholic  (gudumba)

Sleep : Adequate.

FAMILY HISTORY:

No relevant family history. 

GENRAL EXAMINATION :

Patient is conscious, non co-operative.

There are no signs of icterus, clubbing, pallor, cyanosis,

 lymphadenopathy.

VITALS:

Temperature- afebrile

Pulse rate- 148 bpm

Respiratory rate - 22cpm

BP- 130/80mm Hg

Spo2- 100

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

Cardiac sounds- S1, S2 heard.

RESPIRATORY SYSTEM:

Position of trachea- central

Breath sounds- vesicular

Adventitious sounds- No

ABDOMEN:

Mild tenderness

Palpable mass- none

Hernias orifices- 

Free fluid- mild ascites.

Liver- Not palpable

Spleen- Not palpable

Bowel sound- Yes

CENTRAL NERVOUS SYSTEM :

Patient is conscious 

Speech- normal

No sign of meningitis 

Motor and sensory system- Normal

Cranial nerves- intact

INVESTIGATION: 

9/2/2022

ECG:

DIAGNOSIS : Urosepsis ?

TREATMENT :

8/2/22

Monocef 1g/IV/BD.

Inj. PAN 40 mg.

Inj.TRAMADOL 2amp in 200ml N.S/IV/BD.

Inj. Diclofenac sodium.

IV normal saline.

9/2/22

Soft diet.

IV normal saline.

Inj.meropenem 1gm/IV/BD.

INJ.PAN 40mg IV/BD.

inj.paracetamol 1gm /IV/BD.

inj. TRAMADOL 2amp. In 200ml NS/IV/BD.

Monitor vitals