GM - Elog

Name : J. Mounika

 Roll no :  51

3rd sem student

 This is an online e log book to discuss our patient de- identified health data shared after taking his/ her guardians signed and informed consent.

 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.

Case presentation:

A 50 year old male, farmer , resident of nagarjunsagar came with OPD with decreased urine output and shortness of breath. 

History of present illness

•Pedal edema since 3 months
• Facial puffiness, decreased urine output since 3 months
•shortness of breath since  3 days

History of past illness

Pt was apparently asymptomatic 3 months back, was admitted & Diagnosed as chronic renal failure with anemia
• Dialysis initiated on 15/10/2021, 4 session of HD done, 20 PRBC transferred. 

Treatment history

Not significant

Personal history

diet mixed 

appetite - normal

regular bowel and bladder movements 

-no addictions

Family history

Not significant

Vitals

PR-84 bpm

BP-130/ 70 mm Hg

RR- 24 cpm

GRBS- 136 mg/dl

Temperature- 98.4 afebrile

SpO2-98%

General Examination

Pedal edema present

no pallor, no icterus, no cyanosis, no clubbing , no lymphadenopathy, 

Systemic Examination

RS: BAE+, B/L  IAA crept +

CVS: S1, S2 +

PA:soft, non- tender

CNS: NFD


Investigations


Provisional diagnosis

CKD on MHD

Treatment:

•• Dialysis started on 15/10/2021
4 sessions of HD done

•Fluid restriction <1.5 lit/ day
•Salt restriction <2 gm/day
•Tab. LASIX 40  PO / BD
•Tab. NODOSIS 500 PO/ BD
•Tab. SHELCAL CT / PO/ BD
•Tab. BIO-D3 0.25  PO
•Tab.OROFER × 5   ×PO / BD
•INJ. ERYTHROPIOETIN 4000 IV /SOS



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