80 yr old, right lower abdomen
A 80YEAR OLD MALE,CAME TO CASUALTY WITH CHIEF COMPLAINTS OF PAIN IN RIGHT LOWER ABDOMEN SINCE 1 WEEK
This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
I have 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
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitt
A 80year old male,resident of kodakandla village,worked at pharmacy in Bombay and got retired,came to casualty with chief complaints of pain in right lower abdomen since 1 week.
HOPI:
Patient was apparent asymptomatic 20days back and then he developed fever which was intermittent,low grade,assosiated with chills and rigor.Temperature got down on taking Dolo 650mg.No diurnal variation.No h/o body pains,headache,vomitings, diarrhea.
Weakness of lower limbs since 10days.He is unable to stand on his own.
One week back he developed pain in right sided lower abdomen,pain was pricking type and aggravated on slight movement and pain relieved temporarily on medication.
Decreased urine output and burning micturation since 5days.
Past history:
No similar complaints in past.
In 2010,he got admitted in NIMS,for urinary tract infection and got treated.
H/o urine incontinence since 2010,uses diapers occassionally.
He is a known case of:
Asthma since 30years,h/o renal caliculi 10years back,BPH 10years back,hypertension since 5years and he is on AMLODIPINE-5mg,decreased hearing in left ear since 5-6years and used hearing aid for 1year, not and not using now,h/o recurrent UTI.
Not a known case of TB,Epilepsy.
No history of previous surgeries.
Personal history:
Diet:Mixed
Appetite:Normal
Sleep:He sleeps more in morning and has disturbed sleep at night.
Bowel movements decreased since 5days and was given enema today and he passed stools.
decreased urine output and burning micturation since 5days.
Addictions:consumes alcohol occassionally.
General physical examination:
Patient is conscious,coherent,coperative and well oriented to time,place,person.He is moderately built and nourished.
No signs of pallor,icterus,cyanosis,clubbing,generalised lymphedenopathy,edema.
Vitals:
Temperature:99.6F
PR:86bpm
RS:16cpm
BP:110/70 mmHg
Spo2:98% at room air
GRBS:106mg%
Systemic examination:
CVS:S1,S2 heard,no murmurs.
RS: Bilateral airway present.NVBS Heard
CNS :Memory intact
HMF intact
TONE : RIGHT LEFT
UPPER LIMB. N. N
LOWER LIMB. N. . N
POWER :. RIGHT. LEFT
UPPER LIMB. 4/5 4/5
LOWER LIMB. 4/5. 4/5
REFLEXES :
BICEPS. +++. +++
TRICEPS +++. +++
SUPINATOR +. +
KNEE. +. -
ANKLE +. -
PLANTAR :. FLEXOR. MUTE
Per abdomen:
INSPECTION:
Shape of abdomen:Distended
Flanks:Not full
Umbilicus:Position-center,Shape:normal.
Skin over abdomen:normal.
No engorged veins.
No scars and sinuses.
PALPATION:No local rise of temperature and tenderness is present in right iliac region.
All inspectory findings are confirmed by palpation.
Liver:non tender and non pulsatile,lower border of liver is palpable just below right costal margin.
Spleen:non tender
Kidney: non tender,felt in right and left lumbar regions moves in respiration.
No other palpable swellings and hernial orifices
PERCUSSION:
Fluid thrill and shifting dullness absent.
On percussion of liver:dull note is heard at 3rd ICS
On Percussion of spleen dull note heard and fingers easily passed below left ribs suggesting no spleenomegaly.
AUSCULTATION:
Bowel sounds heard.
Bruit not heard
No venous hum.
INVESTIGATIONS:
On 7-10-2022
Urine creatinine levels are elevated
Serum Na+ levels are slightly low.
HBsAg:Positive.
On 8-10-2022,
Alkaline phosphate elevatedAlbumin levels decreased.
At 7am,
At 1pm,
On 11-10-2022,
PROVISIONAL DIAGNOSIS:
Complicated urinary tract infection with acute kidney injury.
TREATMENT:
1. TAB. NITROFURANTOIN 100 MG PO/BD
2. INJ. NEOMOL 1 G/IV/SOS (IF TEMP.>101 F)
3. IV FLUIDS NS @ 75 ML/HR
4. INJ. PIPTAZ IV/OD
5. TAB. DOLO 650 MG PO/TID
6. INJ. PAN 40 MG /IV/OD
7. T. TAMSULOSIN 0.4 MG/PO/HS
8. INJ. ZOFER 4 MG/IV/OD.
This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
I have 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
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitt
A 80year old male,resident of kodakandla village,worked at pharmacy in Bombay and got retired,came to casualty with chief complaints of pain in right lower abdomen since 1 week.
HOPI:
Patient was apparent asymptomatic 20days back and then he developed fever which was intermittent,low grade,assosiated with chills and rigor.Temperature got down on taking Dolo 650mg.No diurnal variation.No h/o body pains,headache,vomitings, diarrhea.
Weakness of lower limbs since 10days.He is unable to stand on his own.
One week back he developed pain in right sided lower abdomen,pain was pricking type and aggravated on slight movement and pain relieved temporarily on medication.
Decreased urine output and burning micturation since 5days.
Past history:
No similar complaints in past.
In 2010,he got admitted in NIMS,for urinary tract infection and got treated.
H/o urine incontinence since 2010,uses diapers occassionally.
He is a known case of:
Asthma since 30years,h/o renal caliculi 10years back,BPH 10years back,hypertension since 5years and he is on AMLODIPINE-5mg,decreased hearing in left ear since 5-6years and used hearing aid for 1year, not and not using now,h/o recurrent UTI.
Not a known case of TB,Epilepsy.
No history of previous surgeries.
Personal history:
Diet:Mixed
Appetite:Normal
Sleep:He sleeps more in morning and has disturbed sleep at night.
Bowel movements decreased since 5days and was given enema today and he passed stools.
decreased urine output and burning micturation since 5days.
Addictions:consumes alcohol occassionally.
General physical examination:
Patient is conscious,coherent,coperative and well oriented to time,place,person.He is moderately built and nourished.
No signs of pallor,icterus,cyanosis,clubbing,generalised lymphedenopathy,edema.
Vitals:
Temperature:99.6F
PR:86bpm
RS:16cpm
BP:110/70 mmHg
Spo2:98% at room air
GRBS:106mg%
Systemic examination:
CVS:S1,S2 heard,no murmurs.
RS: Bilateral airway present.NVBS Heard
CNS :Memory intact
HMF intact
TONE : RIGHT LEFT
UPPER LIMB. N. N
LOWER LIMB. N. . N
POWER :. RIGHT. LEFT
UPPER LIMB. 4/5 4/5
LOWER LIMB. 4/5. 4/5
REFLEXES :
BICEPS. +++. +++
TRICEPS +++. +++
SUPINATOR +. +
KNEE. +. -
ANKLE +. -
PLANTAR :. FLEXOR. MUTE
Per abdomen:
INSPECTION:
Shape of abdomen:Distended
Flanks:Not full
Umbilicus:Position-center,Shape:normal.
Skin over abdomen:normal.
No engorged veins.
No scars and sinuses.
PALPATION:No local rise of temperature and tenderness is present in right iliac region.
All inspectory findings are confirmed by palpation.
Liver:non tender and non pulsatile,lower border of liver is palpable just below right costal margin.
Spleen:non tender
Kidney: non tender,felt in right and left lumbar regions moves in respiration.
No other palpable swellings and hernial orifices
PERCUSSION:
Fluid thrill and shifting dullness absent.
On percussion of liver:dull note is heard at 3rd ICS
On Percussion of spleen dull note heard and fingers easily passed below left ribs suggesting no spleenomegaly.
AUSCULTATION:
Bowel sounds heard.
Bruit not heard
No venous hum.
INVESTIGATIONS:
On 7-10-2022
Urine creatinine levels are elevated
At 7am,
At 1pm,
PROVISIONAL DIAGNOSIS:
Complicated urinary tract infection with acute kidney injury.
TREATMENT:
1. TAB. NITROFURANTOIN 100 MG PO/BD
2. INJ. NEOMOL 1 G/IV/SOS (IF TEMP.>101 F)
3. IV FLUIDS NS @ 75 ML/HR
4. INJ. PIPTAZ IV/OD
5. TAB. DOLO 650 MG PO/TID
6. INJ. PAN 40 MG /IV/OD
7. T. TAMSULOSIN 0.4 MG/PO/HS
8. INJ. ZOFER 4 MG/IV/OD.
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