Disclaimer:-
This is a HIPAA de-identified open-online-patient-record with initial information in patient's voice, posted here december 2016 after collecting informed patient consent (form downloadable here) by BMJ Elective Student.
As said by relatives,
In 2012, mid june she complained of extreme weekness. She consulted her family doctor, He checked on CBC and found Hb to be extremely low (6.5). He advised her to visit a bigger hospital.
We admitted her to higher center in delhi. Dr. prescribed us to transfuse 5 units of blood and aditional medication. She was there for a month and things became normal. She went back to Bengal. However, the prescribed oral medication of blood pressure and other suppliments continued.
Aunt again travelled to Delhi to attend a family function in 2013. She again felt unwell and was readmitted.
A biopsy was done under the consultation of Oncologist to check why the blood is not generated. The outcome of test was negative and this eradicated any fear of blood cancer but was advised to see a Nephrologist. She was there for half a month and brought to normalcy, however medication continued. She was prescribed Epofer 4000 injection for blood support.
4. As advised by our family doctor Dr. Anjan Dey (Delhi) we took her to Medanta Medicity for a check up under Nephrologist Dr. Ritesh Sharma. He checked on Blood reports and past records and prescribed medicines and asked for regural visits.
However, Aunt had urgent work in Bengal and she went back (she was the Head Mistress of ... School). She consulted local doctors and continued earlier medicines.
In 2014 unfortunately my uncle Mr... became seriously ill and expired due to multiple orgaon failure in Delhi and due to which we could not focus much on aunt.
In 2015-16 she developed Venous Ulcer in both her legs (lower limb) and consulted local doctor. This became acute by the end of 2016 and on mid. Dec she complained of acute respiratory disorder, low urine outcome and high fever. She was admitted in Hospital(General Physician).
2 days later, I rushed and with doctor's advise, I took her to bigger Hospital, and admitted under Nephrologist.
She was there for more than 20 days and discharged after situation came to normalcy. But she continued urinal problem.
Once back in home I opted for a blood test where I found creatinine to be 3.9 and Urea to be 276. She had fever, lack of appetite and pain in stomach. I guessed there could also be a possibility of urilogical disorder so we brought her again to hospital.
- Investigations done in the current hospital (mentioned in the narrative above)
URINE FOR COMPLETE TEST (routine + microscopic)/ URINE R/M - ]
Parameter Value Unit
PHYSICAL EXAMINATION
CHEMICAL EXAINATION
MICROSCOPIC EXAMINATION
Parameter Value Unit
PUS CELL Plenty
EPITHELIAL CELL 2 - 3
RBCs 2 - 3
CAST Granular
CRYSTAL Nil
BACTERIA Present (+)
OTHERS
Urine Culture & Sensitivity Culture Report -
Microscopy URINE FOR CULTURE AND SENSITIVITY Mixed growth, more than three types of colonies grown. Kindly repeat the sample if symptoms persist clinically, ensuring proper collection and transport
CBC-COMPLETE BLOOD COUNT - RC WHOLE BLOOD
Parameter Value Unit
HEMOGLOBIN 10.1 g/dL
TOTAL WBC COUNT 6900 cells/cumm
TOTAL RBC COUNT 3.14 millions/cu mm
PCV 29.7 %
PLATELETS 0.90 lakh/mm3
Parameter Value Unit
NEUTROPHIL 53 %
LYMPHOCYTE 26 %
EOSINOPHIL 18 %
MONOCYTE 03 %
BASOPHIL 00
Parameter Value Unit
MCV 94.6 fl
MCH 32.2 pg
MCHC 34.0 %
LIVER PROFILE ( LFT ) (T.BIL+OT+PT+ALP+PRO+ALB+GLOB+A/G RATIO) -
TOTAL BILIRUBIN 0.7 mg/dl
DIRECT BILIRUBIN 0.3 mg/dl
INDIRECT BILIRUBIN 0.4 mg/dl
SGOT 154 U/L
SGPT 103 U/L
GGT 578 U/L
ALP 322 U/L
TOTAL PROTEIN 8.7 g/dL
ALBUMIN 3.0 g/dL
GLOBULIN 5.7 g/dL
UREA & CREATININE - RC SERUM
Parameter Value Unit
UREA 311 mg/dl
CREATININE 6.1 mg/dl
HbA1C 6.3 % 4.0-6.0 RC Blood Trend Chart
BUN (BLOOD UREA NITROGEN) 145.3 mg/dl 7.0-18.6
9 days later
UREA & CREATININE - RC SERUM
Parameter Value Unit
UREA 69 mg/dl
CREATININE 1.7 mg/dl
CBC-COMPLETE BLOOD COUNT - RC WHOLE BLOOD
Parameter Value Unit
HEMOGLOBIN 6.7 g/dL
TOTAL WBC COUNT 2900 cells/cumm
TOTAL RBC COUNT 2.07 millions/cu mm
PCV 20.0 %
PLATELETS 0.9 lakh/mm3
IRON STUDIES (TIBC) - RC SERUM
SERUM IRON 64 ug/dl
SERUM TIBC 201 ug/dL
TRANSFERRIN SATURATION 31.8 %
SERUM FERRITIN > 1650.0 ng/ml
URINE FOR COMPLETE TEST (routine + microscopic)/ URINE R/M - RC URINE
Parameter Value Unit
PHYSICAL EXAMINATION
CHEMICAL EXAINATION
MICROSCOPIC EXAMINATION
Parameter Value Unit
PUS CELL Plenty
EPITHELIAL CELL 4 - 5
RBCs 7 - 8
CAST Granular
CRYSTAL Nil
BACTERIA Present (+)
OTHERS Nil
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