A 46 female patient with Pain abdomen,fever

This is 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 patients 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 comment box is welcome. 

I've 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 a diagnosis and treatment plan.  

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

CHIEF COMPLAINTS:

1. Pain abdomen since 2 months 

2. Fever since 2 months 

HISTORY OF PRESENTING ILLNESS:

Patient came to the casualty with complains of pain abdomen since five days 

The patient was apparently asymptomatic 2 years back when she had white discharge PV for which she took medication but it did not resolve. She had a surgery (hysterectomy) for the same on April 26 2023.

Since then the patient was having on and off episodes of pain abdomen which was of squeezing type and diffuse. It was relieved on taking medication (unknown)

Since five days, the intensity of pain has increased. The pain in the hypogastric region and is of squeezing type. She also complains of pain in the left lower back region which is of squeezing type and radiates towards the groin.

It is associated with vomitings (2 to 3 episodes per day, non-projectile, non-bilious, watery with food particles as contents.)

The patient also complains of fever on and off since two months which is of low grade, intermittent and is associated with chills and rigours and reduced on taking medication (paracetamol 650mg PO/BD)

The patient complains of burning micturition since 2 months. 

No Complains of decreased urine output.

PAST HISTORY :

- Patient was diagnosed with DM2 four days back and not put on any medication

- Not a known case of HYPERTENSION, TUBERCULOSIS, CVA, CAD, THYROID DISORDERS, BRONCHIAL ASTHMA.

Pt undergone hysterectomy in the month of April.

PERSONAL HISTORY

Diet: mixed 

Sleep: adequate 

Bowel and bladder: regular 

Addictions: the patient drinks toddy during festivals 

Allergies: nil

Family history: not significant

GENERAL EXAMINATION

She is conscious, coherent and cooperative;

Pallor present. 

Patient is examined in a well lit room after taking an informed consent.

Bilateral pitting type of pedal edema present 

No signs of icterus, clubbing, cyanosis, generalized lymphadenopathy. 

VITAL AT THE TIME OF ADMISSION: (24/06/23) 

BP: 160/90 mm of hg

PR: 121 bpm

RR: 24cpm 

Spo2: 99% at RA 

Systemic examination:

ABDOMINAL EXAMINATION:

On inspection:

-Truncal obesity is seen. 

-Umbilicus is central and inverted. 

- well healed transverse scar is seen on the lower abdomen. 

-There are no visible pulsations, peristalsis, sinuses or engorged veins. 

PALPATION: 

-There is no local raise of temperature 

-Tenderness is present over the hypogastric region. 

- left renal angle tenderness present 

- Abdomen is soft 

-No organomegaly. 

AUSCULTATION:

Bowel sounds are heard. 

RESPIRATORY SYSTEM EXAMINATION 

-Bilateral air entry is present 

- decreased breath sounds in ISA and IAA

CNS EXAMINATION: 

No functional deficits 

CARDIO VASCULAR SYSTEM

S1 and S2 are heard. No murmurs are heard

Provisional diagnosis:

 Acute left pyelonephritis with lower pole abscess of left kidney with ?LRTI with normocytic normochromic anaemia with De novo DM II

INVESTIGATIONS

 24/06/23

RBS: 101 mg/dl

Serum urea: 15 mg/dL

Serum Creatinine: 0.8 mg/dL

Serum electrolytes

Na+: 136 mEq/L

K+: 2.9 mEq/L

Cl-: 102 mEq/L

Ca2+ (ionized) : 1.09 mmol/L

Urine electrolytes

Na+: 126 mEq/L

K+: 6.9 mEq/L

Cl-: 139 mEq/L

LFT

total billirubin : 0.58 mg/dL

Direct bilirubin: 0.15 mg/dL

AST: 29 IU/L

ALT: 16 IU/L

ALP: 297* IU/L

Total proteins: 4.6 gm/dL

Albumin: 1.7gm/dL

A/G ratio: 0.57

PT: 17

INR: 1.25 

APTT: 35

Hemogram:

Hb: 7.5gm/dL*

Total count: 12,500 cell/mm3*

N/L*/E/M/B: 80/15*/3/2/0

PCV: 22.2vol%*

MCV: 71.6fl*

MCH: 24.2pg*

MCHC: 33.8%

RDW-CV:14.8 %*

RBC COUNT: 3.1 millions/mm3*

PLATELET COUNT: 2.4 lakhs/mm3

Smear

RBC: normocytic Normochromic

WBC: leukocytosis

Platelets: adequate in number and distribution

HEMOPARASITES: no hemoparasites seen

IMPRESSION: microcytic hypochromic anemia

Serology : negative 

CUE: 

Albumin: +

Sugars: nil

Bile salts/ bile pigments : nil

Pus cells: 2-3 cells /hpf

Epithelial cells: 2-3 cells/hpf

No crystals, casts, red blood cells. 

Urine for ketone bodies: negative 

USG ABDOMEN AND PELVIS:

FINDINGS: 

1. Evidence of bulky and altered echotexture of left kidney with perinephric fluid

2. Evidence of 42*35mm hypoechoic area noted in lower pole of left kidney with no internal vascularity (? Abscess) 

IMPRESSION:

Left pyelonephritis with abscess in the lower pole of the kidney

Chest x-ray PA view

ECG: 

2D ECHO:

 

25/06/23

Hemogram:

Hb: 7.9 gm/dL*

Total count: 12,000 cell/mm3*

N/L*/E/M/B: 80/16*/1/9/0

PCV: 23.3vol%*

MCV: 71.3fl*

MCH: 24.2pg*

MCHC: 33.9%

RDW-CV:15.4%*

RBC COUNT: 3.27 millions/mm3*

PLATELET COUNT: 3.15lakhs/mm3

Smear

RBC: microcytic hypochromic

WBC: leukocytosis

Platelets: adequate in number and distribution

HEMOPARASITES: no hemoparasites seen

IMPRESSION: microcytic hypochromic anemia

USG CHEST

FINDINGS: 

-E/o air bronchograms seen in B/L visualized lungs feilds. 

- E/o minimal free fluid Noted in left pleural space with underlying lung collapse. 

- right pleural space normal

- No underlying lung collapse on the right side

IMPRESSION:

- B/L air bronchograms in B/L visualized lungs fields. - S/O consolidatory changes. 

- Left minimal pleural effusion with underlying lung collapse 

Reticulocyte count: 0.5%

Serum electrolytes

 Na+: 133 mEq/L

K+: 2.8 mEq/L

Cl-: 98 mEq/L

Ca2+ (ionized) : 1.10mmol/L

26/06/23

Serum electrolytes

 Na+: 135 mEq/L

K+: 3.2 mEq/L

Cl-: 103 mEq/L

Ca2+ (ionized) : 1.14 mmol/L

Hemogram:

Hb: 7.9 gm/dL*

Total count: 12,000 cell/mm3*

N/L*/E/M/B: 80/16*/1/9/0

PCV: 23.3vol%*

MCV: 71.3fl*

MCH: 24.2pg*

MCHC: 33.9%

RDW-CV:15.4%*

RBC COUNT: 3.27 millions/mm3*

PLATELET COUNT: 3.15lakhs/mm3

Smear

RBC: microcytic hypochromic

WBC: leukocytosis

Platelets: adequate in number and distribution

HEMOPARASITES: no hemoparasites seen

IMPRESSION: microcytic hypochromic anemia

HbA1c: 6.9%

Stool for occult blood : negative 

Serum ferritin: 

Review USG I/V/O liquefaction status of the abscess:

-e/o 60*36mm hypoechoic collection noted in the lower pole of the left kidney with 30-40% liquefaction status with internal echoes and septations

- e/o mild perinephric collection and peri nephric fat stranding. 

Left kidney -12. 2*6.5 cms (increased size and altered echotexture) 

IMPRESSION:

Left pyelonephritis with abscess in the left lower pole with 30-40% liquefaction status. 

27/06/23

INVESTIGATIONS

Hemogram:

Hb: 8gm/dL*

Total count: 12,700 cell/mm3*

N/L/E/M/B: 75/16*/2/7/0

PCV: 24.6vol%*

MCV: 75.5fl*

MCH: 24.6pg*

MCHC: 33.8%

RDW-CV:17.2%*

RBC COUNT: 3.25 millions/mm3*

PLATELET COUNT: 3.43 lakhs/mm3

Smear

RBC: microcytic hypochromic

WBC: leukocytosis

Platelets: adequate in number and distribution

HEMOPARASITES: no hemoparasites seen

IMPRESSION: microcytic hypochromic anemia

Serum urea: 18 mg/dL

Serum Creatinine: 0.8 mg/dL

Serum electrolytes

Na+: 134mEq/L

K+: 4.3mEq/L

Cl-: 104mEq/L

Ca2+ (ionized) : 1.03 mmol/L

URINE C/S

65/M C/O PAIN ABDOMEN,? ALCOHOLIC GASTRITIS

This is 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 patients 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 comment box is welcome. 

I've 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 a diagnosis and treatment plan.  

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

CHIEF COMPLAINTS:

Patient came to the casuality with chief complaints of abdominal pain since 5 days.

HOPI:

Patient was apparently asymptomatic 5 days back then he developed pain in the abdomen more in the epigastric region , burning type , with no radiation ,Aggravated with food intake and relieved on taking medication.

Had similar complaints 1 year back - went to the hospital with abdominal pain and was diagnosed as jaundice for which he was treated.

DAILY ROUTINE:

He wakes up at 6 am and gets freshened up. Drinks tea at 7 am followed by breakfast ( rice with curry) at 9 am. Leaves home for work( works as Shepard) at 9am and works till 7 pm. In between eats lunch at 2 pm and drinks tea at 5 pm. Eats dinner at 8 pm and sleeps at 9 pm.

PAST HISTORY:

Not a k/c/o Dm, Htn, asthma, Epilepsy, thyroid disorders, cad, cvs

Had similar complaints 1 year back - went to the hospital with abdominal pain and was diagnosed as jaundice for which he was treated.

SURGICAL HISTORY:

Operated for B/l hydrocele and hernia 20 years back.

PERSONAL HISTORY:

Diet: Mixed

Appetite: decreased 

Sleep: Adequate

Bowel and bladder movements: Regular

Addictions: 

Alcohol consumption since 45 years every day and occasionally since 10 years.

Smoking since 40 years stopped 1 year back.

GENERAL EXAMINATION:

Patient is conscious,coherent,cooperative

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema.

Temp:97.8F

Bp:120/80 mm Hg

Rr:18 cpm

Pr:81 bpm

SYSTEMIC EXAMINATION:

PER ABDOMEN 

Inspection:

- Abdomen is obese

- Umbilicus is central

- All quadrants move equally with respiration.

- No scars, sinuses, engorged veins

Palpation:

- soft

- Tenderness present over left hypochondrium, epigastric region.

- No local rise in temperature 

- All the inspectory findings are confirmed

Percussion:

Resonant 

Auscultation: 

Bowel sounds heard.

CNS: nfnd

CVS: S1 S2 heard,No murmurs 

RS: blae+ , NVBS heard

Investigations:

24/6/23

Hemogram:

Hb-11.9 g/dl

Tlc-6500

Pcv-35.1

RBC -4million/mm³

Platelet count-1.5 lakhs

Blood urea- 17 mg/dl

Liver function test:

Serum Electrolytes:

Blood urea-17 mg/dl

Serum Creatinine -1.0 mg/dl

Serum Amylase-29 Iu/L

SERUM LIPASE-10 Iu/L

Complete Urine Examination:

SEROLOGY-NEGATIVE

Random Blood sugar- 131 mg/dl

25/6/23

Fasting blood sugar- 104 mg/dl

Prothrombin time- 17 seconds

Aptt- 35 seconds

Inr-1.25

GLYCATED HEMOGLOBIN - 6.5

LDH- 249

Peripheral Smear-

Serum electrolytes-

26/6/23:

27/6/23:

Hemogram 

Serum Electrolytes:

Liver function test:

28/6/23:

29/6/23:

DIAGNOSIS:

Pain abdomen secondary to ? Alcoholic gastritis? Acute pancreatitis 

TREATMENT:

- Nbm till further orders

-Iv fluids: Ns, RL, DNS @ 100ml/hr

- inj. Thaimine 200mg iv/bd

- inj. Tramadol 1 amp in 100ml ns/iv/ sos

- inj. Pan 40 mg/iv/od

- inj zofer 4 mg iv/sos

- inj. Buscopan im/sos

47 Y/M Diabetic since 10 years,anemia under evaluation, Hypoglycemia .

This is 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 patients 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 comment box is welcome. 

I've 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 a diagnosis and treatment plan.  

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

Pt c/o Unresponsiveness since 5 am on 18/6/ 23

HISTORY OF PRESENTING ILLNESS:

Pt was apparently asymptomatic 10 years ago  went to hospital for routine checkup and was diagnosed with DM type 2 ,since then he was on tab.Glimi M1 500 mg Po/Od.

Patient complains of decreased appetite since 6 months .

Patient was alright 1 week ago,pt came to casualty with a Hypoglycemic episode ( Giddiness) managed conservatively and not willing for admission at that time.

Patient was alright for 1 week bought to casualty,his Grbs at presentation was 35 mg/dl.

After starting 25 D 100 mlIv/Stat,then Grbs was 168 mg/dl,pt became responsive.

C/o Burning micturition since 4 days .

No c/o fever,cold,cough, vomiting,loose stools

No c/o Sob,chestpain, palpitations,orthopnea,PND .

No c/o pedal edema, Facial puffiness, decreased urine output.

On 20/6/23 pt had fever spikes (103.F ) high grade , intermittent,not associated with chills and rigor.

C/o Vomitings 2 episodes food as content,non projectile,non bilious.

C/o loose stools 4 episodes  

Past History:

Operated for cataract 20 years ago.

Personal History:

Appetite - decreased

Diet-mixed

Sleep- adequate

Bowel and bladder movement - Regular

Addictions- 5-6 cigarettes/day since 20 years 

Occasional alcoholic since 20years. Ii

Daily routine:

He used to be a bus driver for 10 years 

He started driving a lorry driver after his son death he stopped working as lorry driver .

Started driving an Auto  for 2 years then he stopped working 6 months back .

General Examination:

Pt is conscious, coherent, cooperative

No pallor, icterus, cyanosis, clubbing, lymphadenopathy,edema.

Vitals:

Temperature -afebrile at presentation

Fever spikes since 20/6/23 

Bp-150/80 at presentation

Pr- 102 BPM

Rr-16cpm

Grbs-35 mg/dl

Spo2-98%@RA

Input /output charting:

18/6/23-

Input-1760 ml, Output -1100ml

20/6/23-

Input-1100 ml, Output -1200ml

Clinical images:

SYSTEMIC EXAMINATION:

CVS:Apex 5th ICS medial to mid clavicular line,

S1,S2 heard ,no murmur

RS:Tracheal central

Chest elliptical

bilaterally symmetrical

Chest movements normal

Normal vesicular breath sounds heard

P/A :Soft,Non tender

No organomegaly .

CNS:No focal neurological deficit.

Investigations:

Serology- Negative

Rbs- 90 mg/dl

Serum Uric acid-7.7 mg/dl

Serum creatinine - 1.9 mg/dl

Blood urea- 46 mg/dl

USG Abdomen:

20/6/23

Serum creatinine -2.0 mg/dl

Blood urea- 36 mg/dl

Fbs-157mg/dl

21/6

PROVISIONAL DIAGNOSIS:

Hypoglycemia secondary to oral hypoglycemic agents with ?Hospital Acquired Diarrhoea (Resolving)with Anemia with k/c/o DM-2 since 10 years with ?diabetic nephropathy

TREATMENT:

1.Iv fluids NS @ 75ml/hr strict I/o charting

 2. stop oral hypoglycemic agents until further orders.

3. inj. Neomol 1gm/iv/sos ( if temp>= 101F)

4.inj. Zofer 4mg / iv/ sos

5. inj. metrogyl 500mg /iv/ tid

6. Tab sporolac 2 tabs po/tid

7. Tab. baclofen 10mg /po/bd

8.Tab dolo 650 mg PO/sos

9.ors solution 200ml after every stool

10.GRBS 7. Profile monitoring

11.Vitals monitoring 2nd Hourly

50/F with diabetic keto acidosis

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 patients 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 comment box is welcome .

A 50year old female patient who resides at presented to casualty with complaints of  pain abdomen 2 days back, regurgitation of food .

Patient was apparently asymptomatic 15 years back then she had a episode of giddiness,was  taken to hospital and diagnosed with Hypertension  and on regular medication MET-XL25 mg.

Till 6 years back she is doing well developed Bilateral knee joint pain for which  she was advised to take anlgesics .

She started to take antacid medication since 4 years 

1 month back patient developed facial puffiness,pedal edema was taken to nearby hospital and  was told she is having Fatty liver managed conservatively from then she used to develop pedal edema on &off .

Patient complaining of  loss of appetite, regurgitation of food, difficulty in swallowing

5 days back 

1 episode of vomiting bilious ,non projectile ,food as content  

3 episodes of loose stools non sticky,foul smelling, yellow coloured, small quantity,not associated with blood  

Abdominal pain squeezing type non radiating , continuous in nature,with no aggravating and relieving factors 

Pt presented to casualty on 3/6/23 evening 

On checking her GRBS it was found to be HIGH.

URINE for ketone bodies found to be positive.

Past History:

Not a k/c/o Tb, epilepsy,cad,CVD,Asthma, thyroid disorders.

Family History 

Not significant

Personal History:

Pt is having loss of appetite, vowel movements increased ,micturition- 7-8 times /day ,sleep - inadequate,No addictions.

Daily routine:

Patient used to be a maid 6 years back and stopped working due to bilateral knee joint pain and used to stay at home

Patient wakes up at 6:30 am ,does her daily activities and drinks Java at around 7:30 , breakfast by 8 am ,watches Tv will have her lunch by 2 pm ,takes Tea by 6 pm and dinner by 9 pm and sleeps by 10 pm.

General Examination:

Pt is conscious, coherent,cooperative 

Pallor present

no icterus,cyanosis, clubbing,generalised lymphadenopathy,edema.

Clinical images:

picture showing pale palpebral conjunctiva

VITALS:

Bp-130/80 mm Hg

Pr-97 bpm

Rr-25 cpm

Temperature:Afebrile

Spo2: 98%@RA

GRBS- HIGH

SYSTEMIC EXAMINATION:

P/A:

Inspection:

Abdomen is distended

Infraumblical vertical scar present

No sinuses,,pulsations, peristalsis.

Umblicus is central and inverted

All quadrants of Abdomen move equally  with respiration.

Palpation:

No local rise of temperature

Tenderness present in the Right ,Left Hypochondrium and Epigastrium.

No fluid thrill 

Liver is palpable

Spleen not palpable

Percussion:

Resonant note is heard on percussion

 shifting dullness negative

Auscultation:

Bowel sounds are heard.

Cvs:

S1,S2 heard No murmurs

CNS:

No focal neurological deficit 

Rs:

Bae+

Normal vesicular breath sounds heard.

Investigations:

URINE for Ketone bodies: Positive 

Serum osmolaity:

Glycated Hemoglobin 

Abg and serum electrolyte values

Hemogram 

Liver function test

Blood Culture Report:

Urine Culture Report:

Usg Abdomen:

No sonological abnormalities detected

Chest X ray:

Ecg:

2d echo

Provisional Diagnosis:

?Diabetic ketoacidosis ?Starvation ketoacidosis with Acute Gastroenteritis with Denovo DM2.

Treatment:

1.IVFluids NS @100ml/hr

2.Inj.HAI  infusion 1ml(40U)in 39 ml NS@4ml/hr increase or decrease according to GRBS

3.IV 5Dextrose@50ml/hrincrease or decrease according to GRBS

4.Strict I/O CHARTING

5.monitor Vitals Hourly

1801006052 Long case

 This is 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 patients 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 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.

A 13 year old female patient resident of    Suryapet presented to OPD with 

CHIEF COMPLAINTS

Vomitings  since 1 day  

Shortness of breath since 1 day

HISTORY OF PRESENTATION ILLNESS

 Patient was apparently asymptotic till the age of 11years

She was sent to hostel for studies

After few days of hostel stay she noticed that bilateral swellings  over the neck 5-6 in number 

History of fever which is insidious in onset,intermittent, not associated with chills and rigors no evening rise of temperature 

History of cough which is intermittent and not associated with any sputum 

 for which she was taken to RMP, he  has initiated her on ATT as her mother has also has Tuberculosis 

They used ATT for 2months started in the month of June 2021

After initiating ATT fever was  increased so they discontinued ATT and was referred to Hyd by the RMP

Patient was taken to hospital where she was evaluated for tuberculosis  but was tested as negative for Acid fast bacilli, culture,cbnaat. ,she also  complained  of  bilateral knee and wrist joint pains.

In hospital they suspected it to be autoimmune and started her on Tab Wysolone and Tab HCQ ,which she used for 15 days and stopped.

Patient was tested for -

ANA ELISA-equivocal,ANA IFA-negative

Anti Ds DNA ELISA-Positive,Anti Ds DNA IFA negative.

She was taken to another local hospital with c/o joint pains,facial puffiness,pedal edema,fever ,cough

Lymph node biopsy was done in the month of May 2022

Mycobacterial gene expert test was done and was confirmed with Tuberculosis and was started on ATT for 6 Months.

 Before starting ATT attendors had noticed that she is developing facial rash  ( black in colour)  rash all over the body and Hair loss.

Patient was fine till the month of January 2023 ,she developed generalised edema due to proteinuria. 

Fever was on and off from then which got  relieved on taking medication.

Pedal edema  since 2 weeks  till the level of knee, Abdominal distension since 1 week .

March 13: She had Vomitings 4 -5 episodes non  bilious ,food as content.

Shortness of breath of grade 2 

PAST HISTORY:

Patient is a known case of Tuberculosis, diabetes, Hypertension, epilepsy,asthma.

PERSONAL HISTORY:

Daily routine - Patient wakes up at 7 am does her daily routine work , previousy she used to stay at hostel ,goes to school at 9 am ,lunch at 1 pm ,comes back from school  take some snack ,playtime till 6 pm, dinner at 7 :30 pm and goes to sleep at 10 pm .

Now patient wakes up at 7 am does her routine work,take break fast at 9 am and takes rest lunch at 1 pm ,snacks ,fruits at 4:30 ,8 pm dinner,9 pm sleep.

Appetite - decreased.

Diet - Mixed

Bowel and bladder movements: patient complained of decreased urine output,bowel movements are normal .

Sleep: inadequate 

FAMILY HISTORY:

Mother is a known case of Tuberculosis ,died 6 months ago 

BIRTH HISTORY: She is the first child born out of 2nd degree consanguineous marriage

MENSTRUAL HISTORY

Not attained menarche .

GENERAL EXAMINATION:

Patient is conscious coherent and cooperative ,well oriented to time place and person poorly built and moderately nourished .

Pallor present

Icterus absent

Cyanosis absent

Clubbing absent

Lymphadenopathy absent

Bilateral pedal edema present

Vitals:

Temperature

 Pulse rate:88beats /min

Blood pressure:130/70

Respiratory rate:22cycles per minute.

SYSYTEMIC EXAMINATION:

Abdominal examination:

Inspection:

Shape - slightly distention.

Umbilicus - Inverted

No visible pulsation,peristalsis, dilated veins and localized swellings.

Palpation:

soft, tenderness in right and left Hypochondrium, epigastrium.

Percussion:

shifting dullness present.

Auscultation:

Bowel sounds heard

Respiratory examination:

Bilateral air entry present

Dull note heard on percussion 

Vocal resonance decreased.

Cvs examination

S1 s2 heard, no murmurs

Jugular venous pressure:

https://youtube.com/shorts/nx6XLEUBxJY?feature =share

CNS examination:

No focal neurological deficits

Higher mental functions normal

Cranial nerves normal

Sensory examination normal

Motor examination normal

Reflexes normal.

INVESTIGATIONS:

14/03

Serum electrolytes:

Sodium 136 meq/l

Potassium 4.4 mEq/l

Chloride 106 meq/l

Serum creatinine 0.6mg/dl

Esr 70 mm

CRP neagtive

Blood urea 29 mg\dl

FBS 100 mg\dl

Blood group 0+

Rheumatoid factor negative

HIV non reactive

Hbs ag non reactive.

COMPLETE URINE EXAMINATION:

Colour pale yellow

Appearance: clear

Acidic

Specific gravity 1.010

Albumin ++

RBC: 4-6

No sugar, bile salts, bile pigments,  casts, amorphous deposits

Pus cells 3 to4 \hpf

Epithelial cells 2 to 3 \hpf

ULTRASOUND ABDOMEN:

Liver,gallbladder,pancreas,spleen, uterus,ovaries normal

Moderate ascites

Bilateral pleural effusion

Moderate pericardial effusion

Bilateral grade 2 rpd change

COMPLETE BLOOD PICTURE:

14/03:

Hb- 6.8g%

Wbc-5,400

Platelet:1,20,000

Pcv:23.3

MCv:77.4

Mch:22.6

Mchc:29.2

Rdw:20.1

RBC:3,01

Smear- Anisopoikilocytosis,with microcytes ,tear drop cells ,pencil forms.

15/03:

COMPLETE BLOOD PICTURE: 

Hb 7.5 g\dl

WBC 4200 cells\cumm

Neutrophils 60

Lymphocytes 36

Eosinophils 02

Monocytes 02

Basophils 0

Pcv 24.6 vol%

Mch 76.4 fl

Mchc 30.5%

Rdw 20.6 %

Rbc count 3.2 million\cumm

Platelet 1.57 laksh\cumm

Smear normocytic normochromic anemia

 16/03:

Hb-7.2g%

Pcv-23.7

Mcv-70

Mch: 22.1

Mchc:20.4

Rdw:20.

15/3:

Serum creatinine 1.0 mg\dl

Serum electrolytes:

Sodium 1.37 meq\l

Potassium 4.7

Chloride 104

Spot urine protein :393 mg\dl

Spot urine creat 37.8 mg\dl.

Chest X ray:

ECG:

PROVISIONAL DIAGNOSIS :

Autoimmune disease?

Glomerulonephritis secondary to Lupus.

CLINICAL IMAGES

TREATMENT:

Fluid restriction 

Salt restriction

Inj lasix 40mg IV BD

Inj monocef 1gm IV BD

Inj Methyl prednisolone 250mg in 100ml NS IV OD

Tab Aldactone 25mg PO OD

Tab shelcal 500mg PO OD

Vitals monitoring .