Case of Jaundice with AKI

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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.

50-year-old female patient came to OPD with the cheif complaints of 

Fever since 5 days

Swelling of both the legs since 5 days.

HOPI:

Patient was apparently asymptomatic 5 days back then she developed fever for which she went to local hospital where they did some test which was reported to have low platelets count, creatnine  and bilirubin is high and she was referred to our hospital.

Fever was insidious in onset intermittent in nature, aggravated at night  and relieved on medication.

H/o swelling in the both foot  since 5 days.

H/o loose stools  since 5 days back  associated with mucus,non blood stained and no of  episodes are 4.

H/o  pain in the lower limbs from waist to toe which is dragging type and present everytime she moves her legs since 5 days. 

H/o vomiting 2 days back of 3 episodes everytime she consumes food which was associated with nausea and food as it contents. 

Daily Routine:

She wakes up at 6 am and cooks and  do her household  work and has breakfast at 8am ,goes to work and lunch at 12pm and come back to home by 5 pm and dinner at 8pm then sleeps by 9pm.

PAST HISTORY:

She is not an known case of  Diabetes Hypertension Asthma Lerposy and Epilepsy

H/o hysterectomy done 20 years back. 

FAMILY HISTORY:

Not significant

PERSONAL HISTORY:

Diet - Mixed

Appetite - Decreased

Bowel and bladder -irregular

Sleep - Adequate

Addictions - Toddy occasionally on festives. 

Allergies - none. 

GENERAL EXAMINATION:

Patient is conscious ,coherent ,cooperative and was well oriented to time ,place and person 

She is examined in a well lit room, with consent taken.

She is moderately built and well nourished.

Pallor - mild

Icterus - present

Cyanosis - absent 

Clubbing - absent

lymphadenopathy - absent

Pedal edema - present

Vitals :

Temperature - afebrile

Pulse rate - 88 bpm

Respiratory rate - 15 cpm

BP- 120/70 mmHg

SpO2 - 98% on Room air

GRBS - 101 mg/dl

SYSTEMIC EXAMINATION:

CVS : S1 and S2 heart sounds heard

NO murmurs and thrills

RS: Bilateral air entry present position of trachea - central

Vesicular breathsounds are heard

CNS : No NFD

ABDOMEN : Soft and non tender

No palpable masses

Bowel sounds heard 

No organomegaly

Investigations:

Investigations  in previous hospital:

Provisional Diagnosis:

AKI secondary to Leptospirosis.

Treatment:

On 20-08-22

1.IVF - ns, RL @75ml/hr

2.Tab. Pan 40mg PO/OD

3.Tab. Zofer 4mg PO/ BD

4.Tab. paracetamol 650mg PO/TID

5.INJ. Neomol IV / SOS if temp >102°

6Temperature monitoring 4th hourly

7.Strict vitals monitoring - BP,PR 2nd hourly

On 21-08-22

1.IVF - 1 unit ns, RL @75ml/hr

2.Tab. Pan 40mg IV OD BBF

3.Tab. Zofer 4mg IV SOS

4.Tab. DOLO 650mg PO SOS

5.INJ. Neomol 1gm IV / SOS if temp >102°

6.INJ. Lasix 20mg IV BD at 8 am ,4 pm

7.Temperature charting ,RR,BP,PR 8th hourly.