47 year old male with pain abdomen and constipation
Medical case discussion
January 2,2023
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Name : Mounika 8th sem
Roll no : 46
I have been given this case to solve an attempt to understand the topic of "patient clinical analysis data " to develop my competency in reading and comprehending clinical data including clinical history, clinical findings, investigations and come up with a diagnosis and treatment plan
CONSENT AND DEIDENTIFICATION :
The patient and the attendees have been adequately informed about this documentation and the privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.
CASE DISCUSSION
A 47 year old male patient came to the casuality with chief complaints of pain abdomen since 10 days (subsided now), constipation since 10 days
History of present illness :
*Complaints of pain abdomen , right upper quadrant that was subsided after a day
*Complaints of constipation (did not pass faeces , flatus), passed stools after enema
*Decreased urine-out put since a week
*No complaints of pedal edema , SOB , fever
*No complaints of vomiting , loose stools, burning micturation , cough , cough , PND , orthopnea
Past History :
K/c/o Type II DM since 10 years and is on medication
K/c/o Hypertension since 10 years and is on medication
H/o AWMI ( S/P PTCA DES to CAD )
H/o Emphsematous pyelonephritis ( july 2022)
No H /o Asthma, Epilepsy , TB
•History of dialysis
26/12/22 ~First time
28/12/22 ~Second time
Personal History :
Diet-mixed
Appetite- Normal
Sleep-adequate
Decreased urine output(2 to 3 times a day)
Bowel movements - Not regular
No known allergies
Addictions
Alcohol -stopped since 1 year
Family History :
No significant family history
Treatment history :
glicazide,nifidipine since 10yrs daily morning
EXAMINATION
GENERAL EXAMINATION :
Pt is C/c/c
Pallor Present
No Icterus, Cyanosis, Clubbing, Lymphadenopathy,Edema of feet
Vitals
Pr: 82bpm
Bp: 130/70
SpO2: 97% at RA
Temp - Afebrile
Grbs - 297 mg/dl
Systemic Examination
CVS - S1,S2 +
RS - BAE + B/L ISA, IAA crepts +
CNS - NAD
Abdomen - Soft, Non-Tender
Provisional Diagnosis -
AKI on CKD
K/c/o Type II DM , Hypertension since 10 years
Investigations :
25/12/22
27/12/22
31/12/22
2/1/23
Treatment :
Fluid restriction (<1L/day)
Salt restriction (<2g/day)
Dialysis done on 26th ,28th of December 2023
Inj· LASIX 40 mg IV BD
Inj. Piptaz 2.25 GM IV/TID.
Inj. HAI s/c acc to GRBS
Tab. NODOSIS 500mg - PO/BD
Tab. NICARDIA 10 mg PO/BD.
O2 Inhalation SOS.
BP/PR charting 4th hourly.
GRBS charting 6th hourly
Strict I/O charting.
Daily weight monitoring.
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