General medicine E- log

 GENERAL MEDICINE E- LOG

Hi, I am Aziza Ferdose 3rd sem medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.

A 61 YEAR OLD FEMALE PATIENT CAME WITH COMPLAINTS OF PAIN IN LOIN  AND PEDAL EDEMA 

 61 year old female came with complains of 

Decreased urine output associated with 

Burning micturition since 1 year

Pain in loin since 8 months

B/L pedal edema since 20 days 

HISTORY OF PRESENT ILLNESS

Patient was asymptomatic 1 year back then patient complained of pain in loin ( since 8 months ) and burning micturition which increased gradually 

B/L pedal edema pitting type since 20 days associated with pain while walking

Decreased urine output associated with burning micturition since 1 year 

Patient complains of abdominal distention since 5 days and loss of appetite 

PAST HISTORY 

Patient is not a known case of DM, HTN, Asthma, epilepsy, CAD, Thyroid

PERSONAL HISTORY

diet : mixed

appetite : was normal but since 3 days feeling loss of appetite 

addictions: tobacco use for 6 years stopped 1 year back 

sleep: normal 

bowels: regular

micturition: burning micturition 

allergies : no 

VITALS 

temperature : Afebrile

pulse rate : 80 bpm

Bp :130/80 mmHg

GENERAL EXAMINATION 

no pallor , icterus , clubbing of fingers , lymphadenopathy, malnutrition , 

oedema of both feet since 20 days 

CNS : concious,coherent and  cooperative 

CVS :s1 s2 heard

RESPIRATORY SYSTEM :  BAE +, no dyspnoea and wheezing , position of trachea normal , vesicular breath sounds

ABDOMEN :

shape of abdomen : Scaphoid

tenderness :no 

palpable mass: no

hernial orifices : normal

free fluid : no

liver and spleen : not palpable 

INVESTIGATIONS

Random blood sugar : 153

blood urea : 58

serum creatinine : 3.7

Albumin : 2.9 gm/dl

HAEMOGRAM

Hb : 9.3 gm/dl

Total count : 9200 cells/cumm

MCV: 85.0

MCH : 29.6

MCHC : 34.8

Platelet : 2.80 lakhs/cu.mm

LIVER FUNCTION TEST 

Total Bilirubin : 0.73 mg/dl

Direct Bilirubin : 0.31mg/dl

AST :15  IU/L

ALT :10 IU/L

ALKALINE PHOSPHATE :143 IU/L

TP:5.8 gm/dl

ALB: 2.9 gm/dl

A/G:1.01

SERUM ELECTROLYTES 

Na+ :141 mEq/L

k+: 3.5 mEq/L

cl- : 106 mEq/L

ULTRASOUND 

liver : normal , no IBHRD, no F/L , PV andCBD normal

gall bladder : contracted

PCS normal , CMD lost 

no ascitis, lymphadenopathy

Urinary bladder distended minimally 

Examination of multiple cysts in both kidneys 18x12mm in lower pole of right kidney 

examination of 5mm calculus noted in lower pole of right kidney

Impression

grade I fatty liver

bilateral grade II RPD 

ECG 

PROVISIONAL DIAGNOSIS 

Acute kidney injury

TREATMENT 

tab nocidos 500 mg

tab livogen

tab lasix 40 mg 

inj monocef 1gm

inj pan 40 mg 

fluid restriction 

salt restriction 

QUESTION 

What did u learn from the individual patient events that you experienced through their histories, what did you learn from our pgs in terms of analysing the history and clinical examination techniques as well as findings ?

At first the patient joined with complains of decreased urine output associated with burning micturition and pain in loin and pitting type pedal edema.

At first by physically examination and by checking vitals 

 The patient had pitting type pedal edema and abdominal distention

Patient was not a known case of HTN and DM 

 Approach ( by looking at the symptoms )

May be cardiovascular disease or

liver disease or

renal disease

so the ultrasound was done to see the condition of kidneys and also serum creatinine, blood urea ,haemogram , LFT were done to diagnose the problem 

Ultrasound findings showed multiple cyst in both kidneys and 5mm calculus in lower pole of left kidney 

As the patients ultrasound findings said that she is having multiple cysts it may be a cause of :

 back or side pain ( pain in loin as complained by patient )  ,

 kidney stones ( a 5 mm calculus seen in right kidney ) , 

feeling of fullness in abdomen ( patient complains of loss of appetite ) ,

 increased size abdomen due to enlarged kidney ( abdominal distention seen in patient since 5 days ) 

ultrasound impression showed grade I fatty liver and bilateral grade II RPD  

The urine output ( decreased urine output associated with burning micturition ), serum creatinine ( high level seen in the patient ) levels gave the provisional diagnosis as Acute kidney injury 

From the past history :

Patient used tobacco for 6 years and discontinued 1 year back (  may be one f the reason as it reduces the blood flow to the kidneys and cause kidney diseases )