A 45 years old female with hip pain.
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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.
On 25 /3/2022
45 years old women resident of amangal came to the orthopedics opd with
*CHIEF COMPLAINTS:
-Lower back pain and leg pain since 10 days.
-burning micturition,decreased urine output and fever since 3days.
*HOPI:
Patient was apparently asymptomatic 4years back then she developed lower back pain(hip pain),which is insidious in onset gradually progressive and aggrevated after work and sitting,and relieved by medication and rest.
And neck pain since 4 years ,unable to flex and extend the neck .
2years back due to severe back pain ,she went to the local clinic ,she was diagnosed with hypertension for which she on daily medication.
From 2 years onwards she is walking with support.
2 months ago she developed pedal edema which is pitting type and facial puffiness.
10 days back due to the severe hip pain she came to the orthopedics opd .she developed burning micturition and decreased urine output and fever associated with chills since 3 days.
*PAST HISTORY:
Known case of hypertension since 2 years .
Not a known case of diabeties mellitus,asthma, epilepsy,TB
*PERSONAL HISTORY:
Patient was agricultural labourer ,which consitis of mild to moderate work ,picking up weeds and planting seeds and she stopped working since 4 years due to hip pain.From then her daily routine is doing house hold chores like cooking.
Diet-mixed
Appetite-decreased since 10 days
Sleep - adequate
Bowel and bladder movements-
Decreased urine output since 3 days
Bowel is normal
Habits- no addictions
*FAMILY HISTORY:
No similar complaints in the family members.
*GENERAL EXAMINATION:
Patient is conscious coherent and cooperative.
Well oriented to time place and person.
Moderately build and moderately nourished.
Pallor -present
Icterus -absent
Cyanosis- absent
Clubbing- absent
Lymphadenopathy- absent
Edema- pedal edema which is pitting type.
*VITALS:
Temp- 98°F
RR- 16cycles per min
Bp- 130/90mmHg
PR- 83bpm
*SYSTEM EXAMINATION:
Respiratory system-inspection- trachea central,normal respiratory movements,normal vesicular breath sounds.
Cardio vascular system- apex beat normal,JVP raised,S1 ,S2 heard in all areas,no murmurs
Abdominal examination- soft ,non tender,liver span: 14cm
CNS Examination- no focal neurological deficits
*INVESTIGATION:
24/3/2022
•CBP:
Hb- 9.5%
TLC- 19,200
Platelets-2,52,000
*GLUCOSE LEVELS:
•Fasting blood glucose-glucose-182 mg/dl
• post lunch blood glucose- 367 mg/dl
•HbA1c- 7.5 %
•serum albumin- 3.2 g/dl
•serum urea - 76mg/dl
•serum creatinine-3.2 mg/dl
•sodium-139 mEq/L
•Potassium-3.7 mEq/L
•chloride- 98 mEq/L
*Complete urine Examination:
•albumin- +
•sugar - nil
•pus cells- 3-4 cells.
*25/3/2022
On 26/3/2022
PROVISIONAL DIAGNOSIS:
AKI on CKD
Spondyloarthopathy
Denovo Diabeties mellitus
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