General Medicine

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 had vomitings. 

HISTORY OF PAST ILLNESS:
no h/o DM
no h/o HTN
no h/o asthma

TREATMENT HISTORY:
H/O right nephrectomy 

PERSONAL HISTORY: Married
  occupation- farmer
  Appetite- lost
  non vegetarian
  Bowels- regular
  micturition- normal
  known allergies- no
  
VITALS:
temp-
PR-
RR-
BP-
Spo2-
CVS-

Provisional diagnosis:
CRF c s/p right nephrectomy (5/9/18)

clinical images:



Investigations:



Ultrasound:




TREATMENT: 

 

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