Welcome and greetings to every one who are visiting my blog. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.
A 45year old male came to the opd with the chief complaints of loin pain, decreased urine output and pedal edema since 3days and fever and vomitings since 7days.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 7days back the he had fever associated with chills,nauseaand vomitings.Fever was intermittent .Patient had loin pain on both sides and bilateral pedal edema extended upto knee,sob with mild exertion.
HISTORY OF PAST ILLNESS:
Patient is a known case of tuberculosis 3yrs back for which he took treatment for 6months,no history of hypertension, diabetes, asthama, epilepsy.
PERSONAL HISTORY:
Diet:mixed
Sleep: adequate
Bowel and bladder:normal
Addictions: alcoholic since 5years ,vonsumes 180ml every day
FAMILY HISTORY:
No relevant family history
GENERAL EXAMINATION: Patient was concious coherent cooperative and well oriented to time place and person.
No cyanosis, icterus,clubbing, lymphadenopathy
VITALS:
Temperature afebrile
Bo:130/90
Pr:90
Rr:16
Grbs:83mg%
SYSTEMIC EXAMINATION:
ABDOMEN:
Shape-scaphoid,no tenderness,no palpable masses,umbilicus-inverted,no bruit
CVS:
S1& S2heard
No murmur
CNS:
concious,speech is normal,cranial,sensory systems are normal,no neck stiffness.
INVESTIGATIONS:
Provisional diagnosis:AKI secondary to sepsis
Treatment:
Inj.Pipaz2.2gm IV
Inj.lasix 40mgIV
Inj.pan 40mg IV
I j.zofer 4mg IV
IV fluids 2NS 1RL
Syp cremaffin30ml PO OD
Syp.pot klor 15ml PO TID
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