General medicine case discussion
E LOG MEDICINE CASE
04/01/2023
This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed consent.Here we discuss our individual patient's problems through series of inputs from available 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 centered online learning protfolio and your valuable inputs on comment box is welcome.
Name : Mamatha
Roll no : 65
2020 Batch
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 comeup with Diagnosis and Treatment plan.
CASE DISCUSSION:
Date of admission : 02/01/2023
A 65 year old male who is a potter came to causality with ,
Chief Complaints :
Decreased urine output since 3 days associated with vomiting.
HISTORY OF PRESENTING ILLNESS :
Patient was apparently asymptomatic three years ago, he then developed severe body pains for which he consulted local RMP. From then he was on pain killers. Recently, three days ago he noticed decreased urine output associated with vomiting since two days .
PERSONAL HISTORY :
Diet : Mixed
Sleep : Adequate
Bowel and bladder movements : Regular
Allergies : Nil
Addictions : Smoking
PAST HISTORY :
Known history of DM since 1 year and HTN since 2 months.
No history of TB, EPILEPSY, ASTHMA, CVD.
No history of previous surgeries.
No history of blood transfusions.
FAMILY HISTORY :
Insignificant .
GENERAL EXAMINATION
Conscious, coherent, cooperative
Thin built , Moderately nourished.
Pallor : Absent
Icterus : Absent
Cyanosis : Absent
Clubbing of fingers : Absent
Lymphedenopathy : Absent
VITALS :
Temperature : 98.6 F
Pulse rate : 78/min
Respiratory rate : 13/min
BP : 140/80
SYSTEMIC EXAMINATION :
ABDOMEN
Shape: Scaphoid
No palpable mass
Tenderness : Absent
Liver and spleen : Not palpable
Bowel sounds : Present
INVESTIGATIONS:
02/01/2023
Hemogram
Serum creatinine
02/01/2023
Serum Iron
02/01/2023
02/01/2023
Ultrasound
Chronic Kidney Failure
TREATMENT :
Maintenance of Hemodialysis.
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