50 year old female with fever and bilateral pedal edema
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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 diagnosis and treatment plan.
Following is the view of my case :
Date of admission :20-8-2022
Chief complaints :
A 50-year-old female patient came to the casualty with the cheif complaints of fever and swelling of both the legs since 3 days.
History of present illness :
H/o Fever-
Onset - insidious
Duration- since 4 days
Type - intermittant
Associated with chills and rigors.
Diurnal variation present
Increased temperature at night
H/0 constipation for 2 years
Passes stools once every 3 days
H/0 loose stools 4 days back
6 episodes
Non-blood stained
Mucus is present.
H/o of association of pain in lower limbs from thighs to toe everytime she moves her legs since 5 days
Onset- insidious
Duration- 5 days
Type - dragging type
No diurnal variation
Aggravating factors- on walking and while going to bathroom
Relieving factors- on rest
H/o vomiting on 20-8-22 back associated with nausea.
4 episodes , everytime she consumes food.
Contents- food
Bilateral pedal edema since 3 days
Pitting type
Burning micturition present
No history of shortness of breath
4 days back, she went to local area hospital in suryapet and got her reports done which showed,
1. Low platelet count
2. High creatinine and bilirubin
...later her relatives adviced her
to go to a bigger hospital and she came to KIMS.
Daily routine- wakes up at 6:00 am
Cooks Breakfast and eat's at 8:00 am
Goes to work -she is a labourer
Lunch at 12:00 pm
Returns from work at 5:00 pm
Takes rest
Cooks and eats dinner at 8:00 pm
Sleeps at 9:00 pm
No history of contact with rats or other animals.
History of past illness :
Not a known case of,
Hypertension, diabetes, epilepsy, CAD, asthma, thyroid.
Personal history :
Diet - mixed
Appetite - normal
sleep - adequate
Bowel and Bladder movements - regular
Addictions - no
No known allergies
Drug history :
No significant drug history
Family history :
No significant family history
General examination :
Patient is conscious ,coherent ,cooperative and was well oriented to time ,place and person
at the time of examination
SHe is examined in a well lit room, with consent taken.
SHe is moderately built and well nourished.
Pallor - present
Icterus - present
Cyanosis - absent
Clubbing - absent
lymphadenopathy - absent
Pedal edema - present
Vitals : on the day of admission (20/8/2022)
Temperature - Afebrile
Pulse rate - 96 bpm
Respiratory rate - 16 cpm
Blood pressure - 120/70 mmHg
SpO2 - 98% on Room air
GRBS - 101 mg/dl
Systemic examination :
CVS : S1 and S2 heart sounds heard
NO murmurs and thrills
RESPIRATORY SYSTEM : Bilateral air entry present position of trachea - centrall
Vesicular breathsounds heard
CNS : intact
ABDOMEN : Soft and non tender
No palpable masses
Bowel sounds heard
NO organomegaly
Investigations :
On 20-8-22 at suryapet hospital
On the day of admission (20-8-22)
Dengue NS1 antigen , IgG and IgM rapid test:
On day 2 (21-8-22)
Hemogram
Blood grouping
Urine protein and creatinine ratio:
Blood sugar - random
Blood urea - time: 1:59 am
- time: 3:58 am
Blood urea -147 mg/dl
Complete urine exmination
- time : 3:58 pm
ECG
Ultrasound abdomen
Hemogram
Blood urea
Serum creatinine
Serum electrolytes
Hemogram
Liver function tests
Serum electrolytes
Malarial parasite
On day 5 (24-8-22)
APTT
PT
Hemogram
Serum creatinine
ESR
Serum electrolytes
On day 6 (25-8-22)
Hemogram
Treatment:
On 20-8-22
1.IVF - ns, RL @75ml/hr
2.Tab. Pan 40mg PO/OD
3.Tab. Zofer 4mg PO/ BD
4.Tab. paracetamol 650mg PO/TID
5.INJ. Neomol IV / SOS if temp >102°
6Temperature monitoring 4th hourly
7.Strict vitals monitoring - BP,PR 2nd hourly
On 21-8-22
1.IVF - 1 unit ns, RL @75ml/hr
2.Tab. Pan 40mg IV OD BBF
3.Tab. Zofer 4mg IV SOS
4.Tab. DOLO 650mg PO SOS
5.INJ. Neomol 1gm IV / SOS if temp >102°
6.INJ. Lasix 20mg IV BD at 8 am ,4 pm
7.Temperature charting ,RR,BP,PR 8th hourly
On 22-8-22
1.IVF - 1 unit ns, RL @75ml/hr
2.Tab. Pan 40mg IV OD BBF
3.Tab. Zofer 4mg IV SOS
4.Tab. DOLO 650mg PO SOS
5.INJ. Neomol 1gm IV / SOS if temp >102°
6.INJ. Lasix 20mg IV BD at 8 am ,4 pm
7.Temperature charting ,RR,BP,PR 8th hourly
On 23-8-22
1.IVF - 1 unit ns, RL @75ml/hr
2.Tab. Pan 40mg IV OD BBF
3.Tab. Zofer 4mg IV SOS
4.Tab. DOLO 650mg PO SOS
5.INJ. Neomol 1gm IV / SOS if temp >102°
6.T. Doxy 100mg PO BD
7.Temperature charting ,RR,BP,PR 8th hourly
On 24-8-22
1.IVF-1×NS,RL @75 ml/hr
2.INJ.ZOFER 4 mg IV/SOS
3.INJ.NEOMOL 1GM/IV / SOS if temp >101°F
4.T DOXY 100mg PO BD
5.TAB.DOLO 650 mg/PO/SOS
6.BP,PR,RR,TEMP CHARTING 6TH HOURLY
7.SYP cremafin sulfate PO HS 15ml
2.INJ.ZOFER 4 mg IV/SOS
3.INJ.NEOMOL 1GM/IV / SOS if temp >101°F
4.T DOXY 100mg PO BD
5.TAB.DOLO 650 mg/PO/SOS
6.BP,PR,RR,TEMP CHARTING 6TH HOURLY
7.SYP cremafin sulfate PO HS 15ml
On 25-8-22
1.IVF-1×NS,RL @75 ml/hr
2.INJ.ZOFER 4 mg IV/SOS
3.INJ.NEOMOL 1GM/IV / SOS if temp >101°F
4.T DOXY 100mg PO BD
5.TAB.DOLO 650 mg/PO/SOS
6.BP,PR,RR,TEMP CHARTING 6TH HOURLY
7.SYP cremafin sulfate PO/OD/ HS 15ml
2.INJ.ZOFER 4 mg IV/SOS
3.INJ.NEOMOL 1GM/IV / SOS if temp >101°F
4.T DOXY 100mg PO BD
5.TAB.DOLO 650 mg/PO/SOS
6.BP,PR,RR,TEMP CHARTING 6TH HOURLY
7.SYP cremafin sulfate PO/OD/ HS 15ml
Provisional diagnosis: AKI secondary to leptospirosis?
Discharge summary
Date of discharge:
Date:26/08/2022
Ward:FEMALE MEDICAL WARD
Unit:6
Treating faculty:
Diagnosis:
VIRAL PYREXIA WIHT THROMBOCYTOPENIA
AKI.
Case history and clinical findings:
PATIENT CAME WIH THE HISTORY OF FEVER SINCE 4DAYS.
CONSTIPATION SINCE 2 YEARS .
LOOSE STOOLS 4 DAYS BACK[6 EPISODES]
B/L PEDAL EDEMA SINCE 3 DAYS AND BURNING MICTURITION .
Treatment given:
1.IVF NS RL @ 75 ML/HR
2. TAB.PAN 40 MG PO OD.
3.TAB ZOFER 4MG PO OD.
4.TAB PCM 650 MG PO TID .
5.INJ . NEOMAL IV SOS IF TEMP >102 DEGREE .
6.TAB . DOXY 100 MG PO BD .
7.STP.CREMAFFIN 15 ML PO OD
6. TEMPERATURE MONITORING 4TH HOURLY .
Advice at discharge:
1. TAB.PAN 40 MG PO OD.
2.TAB ZOFER 4MG PO OD.
3.TAB PCM 650 MG PO TID . .
4.TAB . DOXY 100 MG PO BD .
5.SYP.CREMAFFIN 15 ML PO OD.
Follow up:
REVIEW AFTER 2 WEEKS IN CASE OF ANY EMERGENCY
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
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