CASE HISTORY 1

 Aug 9,2021

Date of Admission-31-7-21

A 60 year old female presented to OPD with chief complaints of diffuse abdominal pain since 7-10days


HISTORY OF PRESENT ILLNESS

Patient was diagnosed in the nearest hospital 1 year back due to pain in the loin

The Patient didn't undergo for the further treatment at that time.

Patient was suffering from abdominal pain since a month ago and went to the nearest hospital.

Test were performed and the reports shown that she is hypoglycemic, hyponatremia and CRP was extremely high about 92.7mh/l and serum creatinine level was 8.9mg/dl.

She was refered then to KIMS for further treatment.


She is undergoing dialysis(4) since the


She complains of hard stool and prescribed with liq paraffin and milk of magnesia syrup 10ml 3 times a da


She was hypovolemic and undergone blood infusion of 1 unit ( Blood group- B+)


HISTORY OF PAST ILLNESS 

No history of surgery, asthma, TB, CAD, epilepsy.


PERSONAL HISTORY

Decrease appetite 

Bowel movement is irregular since one month

Menopause attained 10years back

No addictions

Sleep adequate 


FAMILY HISTORY

No history of DM, CAD, Asthma and thyroid disorders in the family


GENRAL EXAMINATION 

Patient is conscious, coherent, co-operative.


There is no signs of icterus, clubbing, pallor, cyanosis, lymphadenopathy


VITALS

Temperature- afebrile

Pulse rate- 86 bpm

Respiratory rate - normal

BP- 90/70

Spo2- 100


SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

Thrills- No

Cardiac sounds- S1, S2 


RESPIRATORY SYSTEM:

Dyspnoea present

No wheezing

Position of trachea- central

Breath sounds- vesicular

Adventitious sounds- No

 

ABDOMEN:

Shape of abdomen- scaphoid

Mild tenderness

Palpable mass- No

Hernias orifices- No

Free fluid- No

Bruits- No

Liver- Not palpable

Spleen- Not palpable

Bowel sound- Yes


CENTRAL NERVOUS SYSTEM:

Patient is conscious 

Speech- normal

No sign of meningitis irritation

Motor and sensory system- Normal

Cranial nerves- intact

INVESTIGATIONS:

Urine examination-31/7/21


ABG 1/8/21



HEMOGRAM-31/7/21




SERUM ELECTROLYTES


URINE PROTEIN/CREATININE RATIO-1/8/21


HEMOGRAM-5/8/21


PROTHROMBIN-31/7/21


URINE SODIUM-1/8/21

APTT-31/7/21

TREATMENT


Day-1

Inj. Ceftriaxone 1gm IV/BD
Inj. PAN 40mg IV/OD
Inj. Zofer 4mg IV/TID
Tab. OROFER  XT PD/BD
Tab. NODOSIS 500mg PD/BD
Tab. SHELCAL PD/OD
Inj. Erythropoietin 4000IU/SC/weekly twice
BP monitoring 4th hourly
GRBS 12th 
Strict I/O monitoring hourly
Fluid intake <1.5L per day
ORS sachet 1 packet in 200ml water


Day-2

Inj. Monolef 1gm IV/BD
Inj. PAN 40mg IV/OD
Inj. Zofer 4mg IV/TID
Tab. OROFER XT PD/BD
Tab. SHELCAL CT PD/OD
Inj. Erythropoietin 4000IU/SC/weekly twice
BP monitoring 4th hourly

Day-3

Inj. Ceftriaxone 1gm IV/BD
Inj. PAN 40mg IV/OD
Inj. Zofer 4mg IV/TID
Tab. OROFER XT PD/BD
Tab. NODOSIS 500mg PD/BD
Tab. SHELCAL CT PD/OD
Inj. Erythropoietin 4000IU/SC/weekly twice
BP monitoring 4th hourly
Tab. Lasix-40

Day-4

Inj. Meropengm 500mg IV/BD
Inj. Zofer 4mg IV/TID
Tab. OROFER XT PD/BD
Tab. NODOSIS 500mg PD/BD
Tab. SHELCAL PD/OD
Inj. Erythropoietin 4000IU/SC/weekly twice

PROVISIONAL DIAGNOSIS:
presence of multiple renal cysts is seen in the left 

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