March 01,2022

This is an online E-blog to discuss our patient identified health data shared after taking the consent.

Here we discuss our patient problems through series of inputs available.

I have been given this case to solve in an attempt to understand the topic of "Chronic Renal Failure" to develop my competency in reading and comprehending clinical data including history,clinical findings, investigations and come up with diagnosis and treatment plan.

61 year old Male with decreased urine output and pedal odema

HISTORY OF PRESENTING ILLNESS
 Patient was apparently asymptomatic 3 months back.Then he had a decreased urine output.He had underwent 3 dialysis 20 days back.


HISTORY OF PAST ILLNESS
 K/C/O - Diabetes Mellitus (15years)
                Diabetic foot
                 Hernia
Nota K/C/O- Asthma
                       Epilepsy
                        CVD

                         
TREATMENT HISTORY

. Diabetes - Yes
. Hypertension- Yes
.Asthama - Yes

PERSONAL HISTORY

. Marriage status- Married
. Occupation- Farmer
. Appetite-Normal
. Non-vegetarian
.Bowel - Regular
.Micturition- Normal
 
FAMILY HISTORY
 .Diabetes
 
PHYSICAL EXAMINATION

.Pallor - present
.Pulse rate-  94/min
. Respiration-18 CPM/min
.BP -140/90
.SPO2- 98%
.GBRS-156mg%

SYSTEM EXAMINATION

.CARDIOVASCULAR SYSTEM
-S1 S2 positive

. RESPIRATORY SYSTEM
-BAE positive

. ABDOMEN
- Soft and tender

 INVESTIGATION


TREATMENT
On 2/02/2022

P : 
T.Lasix 40mg BD
T.OROFER XT 1 tab OD
T.NODOSIS 500mg OD
T.SELECALL CT OD
Azithromycin x 3days
Cremaffin 15ml

On 4/02/2022
 T.Lasix 10mg 
Tab.OROFER-XT 1tab
Tab.NODOSIS 500mg
Tab.selcal
T.PANTOP 40mg

On 5/02/2022
Tab.LASIX 40mg 
Tab.OROFER XT 1tab OD 
Tab.NODOSIS 500mg OD 
T.PAN 40mg OD

On 26/02/2022
Inj Tranexa, Pan 80mg in 100ml NS over 30min
Inj zofer 8mg IV

Popular posts from this blog

A 61 year old female

Image
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 histoty, clinical findings, investigations and come up with a diagnosis and treatment plan. CASE: A 61 year old female who is resident of narketpally, came to OPD on 21st november at 12am with Chief complaints of:  - stiffness of muscles of hands and neck  - slurred speech - deviation of mouth towards right. History of present illness: Patient was apparently asymptomatic 10yrs back and then she developed faintness, numbness and tingling sensation, burning sensation of hands and foot espcially during night and was diagnosed with Diabetes Mellitus for which she is on medication. 8months back she developed neck pain, headache, leg pain, body pains and was diagnosed with Hypertension for w...
Read more

General Medicine

Image
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from 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-centred online learning portfolio and your valuable inputs on the comment box is welcome."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 come up with a diagnosis and treatment plan. A 45 year old female patient came to the hospital with the chief complaints of vomiting since 3 days  HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 3 days back, then she h...
Read more