65 yrs female came with low back ache and decreased urine out put

 

Sahithi nalabolu 

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 patient's 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 the comment box"

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.

 RESPIRATORY SYSTEM 

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.

 HIGHER MENTAL FUNCTIONS:

•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: 

•Acute Kidney Injury on Chronic Kidney Disease .

Investigations


Hemogram:


Complete urine examination:



Renal function tests:



Serum electrolyte:



Ultrasound report:                                             
 Impression:
Grade 1 Rpd changes in rightkidney
Grade 2 Rpd changes in left kidney  
Bilateral renal cortical cysts


Bacterial culture and sensitivity:




•Blood urea: 117mg/dl
•Serum iron:72ug/dl
•Serum albumin:3g/dl
•Serum creatinine: 8.8mg/dl
•Rbs: 80mg/dl

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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