E-LOG GENERAL MEDICINE
This is an online e-log platform to discuss case scenario of a patient with their guardians permission.
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, come up with a diagnosis and treatment plan.
Chief complaints:
A 61 year old male came with the chief complaints of pain in the left loin,decreased urine output,fever,constipation and swelling in the legs.
History of presenting illness:
Patient was apparently asymptomatic 15 days back then he had one episode of vomiting followed by fever associated with chills and rigor,then he developed pain in the left loin associated with decreased urine output since 15 days.He developed constipation the next day.
History of past illness:
Known case of diabetes mellitus since 3 yrs.
Known case of Hypertension since 1 yr.
Personal history:
Diet:mixed
Appetite:normal
Bowels:constipation
Micturiton:abnormal
Allergies:absent
Addictions:consumes alcohol since 30 yrs
Non smoker
Sleep:normal
Family history:
No h/o similar complaints in family.
General examination:
Patient is c/c/c well oriented to time,place,person.
Moderately built,moderate nourishment.
Vitals:
Pulse rate:88 beats/min
Respiratory rate:22/min
BP:130/80 mm/hg
Temperature:Afebrile
GRBS:221 mg/dl
Physical examination:
Pallor:absent
Icterus:absent
Cyanosis:absent
Clubbing:absent
Generalised lymphadenopathy:absent
Edema of feet:present
Systemic examination:
CVS:
S1 S2 Heard.
No cardiac murmers
Respiratory system:
Dyspnoea:absent
Wheezing:absent
B/L air entry present
Vesicular breath sounds heard
Abdomen:
Scaphoid shaped abdomen
No tenderness
No palpable mass
No hernial orifices
CNS:
Consciousness:Drowsy
Speech:slurred.
Investigations:
On 26/08/2022
TPR graph sheet.
ECG.
On 27/08/2022
On 30/08/2022
Clinical images:
Provisional diagnosis:
AKI with fever.
Plan of care:
Haemodialysis.
Treatment:
Inj.LASIX 40mg i.v b.d
Inj.NEOMOL 1gm i.v
Tab.DOLO 650 mg po/tid
Syp.CREMAFFIN 5 ml
Inj.PAN 40 MG I.V OD.
Tab.SHELCAL 500 mg po/od
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