General Medicine
29,August, 2022.
A 61 year old male with AKI.
E LOG GENERAL MEDICINE
Hi, I am Pindi Gayatri, 3rd Sem Medical Student.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 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 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.
CHIEF COMPLAINTS
A 61 year old male came to casuality with the chief complaints of pain in left loin.
Decreased urine output,bilateral pedal edema (pitting type),history of fever 6 days back.cold, cough with expectoratum,constipation.
HISTORY OF PRESENT ILLNESS
He came to casuality with the complaints of pain in left loin since 5 days,decreased urine output since 4-5 days,bilateral pedal edema (pitting type)since 5 days.fever since 5 days.
cold and cough with expectoratum. constipation since 4 days.
Patient was apparently asymptomatic 5 days back,then he had 1 episode of vomiting followed by fever associated with chills and rigors,.Then he developed pain in left loin associated with decreased urine output since 5 days.Then he developed constipation associated with diffuse pain abdomen since 4 days.
He had a history of lung infection 1 year back resolved on medication.
HISTORY OF PAST ILLNESS
It is a known case of Diabetes mellitus, since 3 years.
It is a known case of hypertension since 1 year.
It is not a known case of epilepsy, Asthma, CAD, tuberculosis, etc.
TREATMENT/DRUG HISTORY
Diabetes mellitus-since 3 years
hypertension-since 1 year
No Hyperthyroidism
No CAD
No asthma
No tuberculosis
No antibiotics
No hormones
No blood transfusion
No surgeries
PERSONAL HISTORY
Married
Occupation-
Diet-mixed diet
Appetite-lost
Bowels-constipation since 5 days.
Micturition-abnormal
No known allergies
Habits/addictions -
Smoking-daily
Alcohol-occasional
FAMILY HISTORY
Not significant
IMMUNIZATION STATUS
Up to mark
GENERAL EXAMINATION
Patient is coherent,conscious,cooperative,
well oriented to time,place and person.
He is moderately built and moderately nourished.
No pallor
No icterus
No cyanosis
No clubbing of fingers/toes
No lymphadenopathy
edema of feet is present
No dehydration
VITALS
Temperature- 99.8°F
Pulse rate- beats-86/min
Respiratory rate- times-22/min
Blood pressure-130/80 mmHg( left arm)
Spo2-98%at room air at RA litres of O2
GRBS- 241mg/dL
SYSTEMIC EXAMINATION
CVS
No thrills
S1S2 Cardiac sounds heard
No cardiac murmurs
RESPIRATORY SYSTEM
Position of trachea-central
Normal vesicular breath sounds heard
Adventitous sounds-Rhonchi
No dyspnea
No wheezing
ABDOMEN
Shape-scaphoid
tenderness -diffuse tenderness (left)present
No palpable masses
No hernial orifices
No free fluid
bruits present
No bowel sounds heard
Non palpable spleen and liver
P/A:Soft.,mild tenderness in left hypochondrial region,pain on left side of lumbar region.
CNS
Level of consciousness-conscious/alert
Speech- slurred
Signs of meningeal irritation
No stiffness of neck
Kerning's sign:negative
Cranial nerves,motor system,sensory system, glassgow scale- HMF intact.
Reflexes
Biceps Triceps supinator knee ankle
Right ++ ++ ++ ++ ++
Left ++ ++ ++ ++ ++
Plantars-flexor
Cerebral signs
Finger nose In-coordination:No
Knee heel In-coordination :No
PROVISIONAL DIAGNOSIS
AKI (post renal)with urosepsis , fever 2° to ?UTI
With acute pulmonary edema(resolved),emphysematous pyelonephritis left >rigt),bilateral hydrouteronehrosis.
INVESTIGATIONS
On 26th, August
Ultrasound report
ECG
On 27th, August
Ultrasound report
On 28th, August
ECG
29th, August
ECG
RECORDINGS
HAEMODIALYSIS
