A 13 year old female, came with compalints of fever, generalised swelling of boday and hematuria since one month

December 19, 2022

General medicine case discussion

E LOG MEDICINE CASE

19/12/2022

This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 protfolio and your valuable inputs on comment box is welcome.

Name: K. Supraja
Roll no : 60

2020 Batch

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 comeup with Diagnosis and Treatment plan.

Case presentation:
A 13 year old female ,resident of nalgonda, came to general medicine OPD with chief complaints of:
Fever
Generalised swelling of body
Blood in urine   -since one month.
Associated vomiting and loose stools since one month.

History of present illness:
Patient was apparently asymptomatic 1 month back. Then patient developed fever, generalised swelling of body and hematuria since one month.
*Fever- low grade intermittent type relieved on medication
*Generalised swelling of body -pedal edema, facial fluffiness since 1 month
*Hematuria- passage of red colour urine not associated with burning micturition.

Patient gave complaints of associated
*vomiting- non bilious, non projectile 1 episode per day and
* loose stools - 2-3 episodes per day since 1 month.
She was admitted on 16-12-2022..
She has a history of trauma on the right foot 5months back.

Past History:
No history of  similar complaints in the past.
No history of epilepsy,HTN, DM, Bronchial asthma.

Family History:
No Known history of DM, HTN ,TB ,epilepsy and bronchial asthma for his parents.

Personal History:
Mixed diet
Loss of appetite
Adequate sleep
No Burning micturition
Bowel- loose stools
No known allergies

Menstrual history:
AOM: 11years
Regular 5/28 cycle
LMP: 25-11-2022

Drug History:
Paracetamol for fever

Physical Examination:
General Examination:
Conscious, coherent and cooperative
Well oriented to time place and person
Examined in sitting position
Poorly built
Malnourished
pallor present
No icterus
No cyanosis
No clubbing of fingers
No Lymphadenopathy
pedal edema - pitting type

Vitals:
Temperature (afebrile): 98.4degree Fahrenheit
Pulse Rate: 74 beats per minute
Respiratory rate: 18 times per minute
BP: 120/90

Systemic Examination:

CVS:
S1, S2 sounds heard
No audible murmurs
No thrills

Abdomen:
Shape of abdomen: scaphoid
No visible scars
Movement of abdomen moves equally with respiration

Respiratory system:
Bilaterally symmetrical
No visible scars
Position of trachea central
Explanation of chest: symmetrical
Vocal fermitis: equal on both sides
Breath sounds
Vocal resonance
No added sounds

Investigation: Hemogram, CUE, ECG, chest xray, 24hr urine profile

ppittppitpitt

https://drive.google.com/file/d/1WOc-kLBF9UVk_NNrsrdpoOW-aQmlf9Eo/view?usp=drivesdkpitting type of edema

Provisional Diagnosis:

Post infectious glomerulo nephritis- E. Coli / salmonella/ streptococcus

Treatment:

Salt restriction ( <2 gm / day) 

Fluid restriction ( <1.5 lit/ day) 

BP charting 4rth hourly