65 yrs female came with low back ache and decreased urine out put
Sahithi nalabolu
Hall ticket number: 1701006124
Final examination short case:
Case presentation:
A 65 year old female patient came to the hospital with the
Cheif complaints :
•Low back pain since 7 days
•Redued urine output since 7 days
History of Presenting Illness:
Patient was apparently asymptomatic 4 years ago then she developed low back pain of cramping type aggravated on working and was relieved on medications .
Since then, she used to take the medications when the pain appears again.
Patient 2yrs ago with the burning micturition, lower back pain complaints went to a hospital, which on investigations were told to have renal failure. She didn' t take any treatment for it.
Patient presents with decreased urine output and low back pain since 7 days.
Patient Complaints of fever of low grade, intermittent in nature and relieved on medication. It was associated with burning micturition.
No history of chills and rigors, shortness of breath and pedal edema.
Past History:
NSAIDs abuse since 4 years
Medical history:
Not a known case of Diabetes mellitus, Hypertension. Epilepsy, Cardiovascular disease,. Asthma and tuberculosis.
Surgical history:
Had Hysterectomy for a prolapsed uterus 4 yrs back
Family History:
No similar complaints in family
Not significant
Personal history:
Diet: mixed
Appetite:decreased
Sleep: Adequate
Bowel and bladder : Decreased urine output
No known allergies
No addictions
General examination:
Patient is conscious, cooperative and well oriented to time, place and person. She is of thin built.
• pallor-present
•Icterus-absent
•Cyanosis-absent
•Clubbing- absent
•Edema- absent
•Lymphadenopathy- absent
Vitals:
Temperature:afebrile
Pulse rate: 95 bpm
Blood pressure: 110/70 mm of Hg
Respirtaory rate; 16 cpm.
Systemic Examination:
ABDOMEN EXAMINATION
INSPECTION:
•Shape – scaphoid
•Flanks – free
•Umbilicus –central in position , inverted.
•All quadrants of abdomen are moving equally with respiration.
•No dilated veins, hernial orifices, sinuses
•No visible pulsations.
PALPATION:
•No local rise of temperature and tenderness
•All inspectory findings are confirmed.
•No guarding, rigidity
•Deep palpation- no organomegaly.
PERCUSSION:
•There is no fluid thrill , shifting dullness.
Percussion over abdomen-
tympanic note heard.
AUSCULTATION:
Bowel sounds are heard.
CARDIOVASCULAR SYSTEM
INSPECTION:
•Chest wall - bilaterally symmetrical
•No dilated veins, scars, sinuses
PALPATION:
•Apical impulse is felt on the left 5th intercostal space 1cm medial to mid clavicular line.
•No parasternal heave, thrills felt
AUSCULTATION:
•S1 and S2 heard , no added thrills and murmurs heard.
INSPECTION:
•Chest is bilaterally symmetrical
•Trachea – midline in position.
•Apical Impulse is not appreciated
•Chest is moving normally with respiration.
•No dilated veins, scars, sinuses.
PALPATION:
•Trachea – midline in position.
•Apical impulse is felt on the left 5th intercoastal space.
•Chest is moving equally on respiration on both sides
•Tactile Vocal fremitus - appreciated
PERCUSSION:
The following areas were percussed on either sides-
• Supraclavicular-resonant
•Infraclavicular- resonant
•Mammary- resonant
•Axillary- resonant
•Infraaxillary- resonant
•Suprascapular- resonant
•Infrascapular- resonant
• interscapular - resonant.
AUSCULTATION:
•Normal vesicular breath sounds heard
•No adventitious sounds heard.
CENTRAL NERVOUS SYSTEM EXAMINATION.
•Patient is Conscious, well oriented to time, place and person.
•All cranial nerves - intact
•Motor system: Intact
•Superficial reflexes and deep reflexes are present , normal
•Gait is normal
•No involuntary movements
•Sensory system -
-All sensations pain, touch,temperature, position, vibration, are well appreciated.
Provisional Diagnosis:
Investigations
Renal function tests:
Ultrasound report:
Bacterial culture and sensitivity:
Treatment:
◇Tab. LASIX 40 mg PO BD
◇TAB. NODOSIS 500mg PO BD
◇TAB. OROFER XT PO BD
◇TAB. PAN 40mg PO OD
◇TAB. ULTRACET 1/2 TAB PO QID
◇INJ. IRON SUCROSE 1Amp in 100 ml NS ONCE WEEKLY
◇INJ. EPO 5000IU/SC/OD
◇SYRUP. CRANBERRY 15ml PO TID
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