This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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 diagnosis and treatment plan.


C/c: A 50 year old Male came for Dialysis.

HOPI: The patient was apparently asymptomatic one year back then he started having pain in the left lower back. It was insidious in onset, gradually progressive, continuous and dragging pain with no aggravating and relieving factors which lasted for 3 months.

Pain was associated with burning micturition beginning and end of urination.

No continuous flow of urine. The urine was yellow coloured.

History of indigestion and vomitings which were projectile non bilious aggravated on food intake and with food contents.

History of using ayurvedic medications.

The patient was unable to do his daily activities so he was put on dialysis by a higher centre.

He is on dialysis 2 times a week from May 2021.

Past history: History of kidney stones in the right kidney 30 years back.

Hypertension Since one year

Not a known case of diabetes, asthma, TB and epilepsy.

Personal History:

Diet- mixed 

Appetite- normal 

No addictions 

B&b-normal 

Sleep-normal

General Examination:

Patient is conscious, coherent, cooperative, well oriented to time place and person.

Oedema +

No Pallor, Icterus,cyanosis, clubbing and lymphadenopathy.






Vitals

Temp: afebrile

PR- 80 BPM

RR- 17 CPMP

BP- 130/90

Systemic Examination:

RS: NVBS

CVS - S1 &S2 +

P/A - soft and non tender 

CNS- NAD

Investigations:

RBS-101 mg/dl

Haemoglobin- 9.7 gm/dl

Serum creatinine- 7.3mg/dl

Blood Urea- 9mg/dl

ECG


2D ECHO


USG


Treatment and Provisional Diagnosis


















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