GENERAL MEDICINE E-log
NAME: A Sanvith
ROLL NO: 09
21/06/2022
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 36 year old male cement factory worker by occupation came to the opd with chief complains of abdominal distension and abdominal pain which is in right loin radiating to groin associated with decreased urine output since 5 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 year back, then he developed abdominal pain and diagnosed to have renal calculi, for which he took treatment and symptoms got subsided.
He developed pain abdomen and abdominal distension 5 days back associated with decreased urine output and fever
No h/o of chest pain, palpitations, shortness of breath
HISTORY OF PAST ILLNESS:
Not a k/c/o of DM, HTN, Epilepsy, CAD, TB
No h/o surgeries
TREATMENT HISTORY:
Not significant
PERSONAL HISTORY:
Appetite- normal
Mixed diet
Bowel movements- regular
Micturition - decreased
No drug allergy
Alcohol consumption since 15 years
FAMILY HISTORY:
Not significant
GENERAL EXAMINATION:
Patient is conscious, coherent, cooperative
Absence of pallor, icterus, Cyanosis, clubbing, lymphadenopathy, edema
VITALS:
Temperature: Afebrile
Pulse rate: 76 bpm
Respiratory rate:28 cpm
BP: 120/70 mm of hg
Spo2 : 98% at room air
SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM:
Thrills absent
S1, S2 heard
No murmurs
RESPIRATORY SYSTEM:
Normal vesicular breath sounds
Position of trachea is central
No dyspnoea
No wheeze
ABDOMEN
shape of abdomen- distended
No tenderness
No palpable mass
Normal hernial orifices
No free fluid
No bruits
Liver and spleen are not palpable
Bowel sounds heard
CENTRAL NERVOUS SYSTEM:
Patient is conscious
Speech-normal
No signs of meningeal irritation
Motor and sensory system is intact
PROVISIONAL DIAGNOSIS:
POST RENAL AKI SECONDARY TO URETERIC CALCULI WITH URINARY STASIS WITH MOD
INVESTIGATIONS:
17/06/22
18/06/22
19/06/22
20/06/22
21/06/22
TREATMENT:
17/06/22:
INJ PIPTAZ 2.25 gm/IV/TID
IVF- NS @ 50 ML/HR
INJ LASIX 40 mg/IV/BD
INJ PAN 40 mg/IV/OD
INJ ZOFER 4 mg/IV/TID
INJ BUSCOPAN 1 amp/IV/SOS
TAB UDICIU 300 mg PO/BD
SYP LACTULOSE 1ml/PO/HS
TAB RANTAC 150 mg PO/OD
18/06/22
INJ PIPTAZ 2.25 gm IV/TID
IVF NS @ 100 ml/hr
INJ LASIX 40 mg/IV/BD
INJ ZOFER 4 mg IV/TID
INJ TRAMADOL 100ml NS IV/TID
TAB UDILIV 300 mg PO/BD
TAB RANTAC 150 mg PO/ OD
19/06/22
INJ MEROPENEN 100mg IV/OD
IVF NS @100ml/ hr
INJ LASIX 100 mg /IV/BD
INJ ZOFER 4 mg IV/BD
INJ TRAMADOL 1 amp 100ml NS/ SLV/TID
TAB UDILIV 300 mg PO/TID
TAB RANTAC 150 mg PO/BD
20/06/22
INJ MEROPENEM 800 mg IV/ OD
IVF ND @100 ml/ hr
INJ LASIX 40 mg /IV/BD
INJ ZOFER 4 mg IV/BD
INJ TRAMADOL 1 amp 100ml NS/ IV/TID
TAB UDILIV 300 mg PO/TID
TAB RANTAC 150 mg PO/BD
21/06/22
INJ MEROPENEM 500 mg IV/ OD
IVF ND @100 ml/ hr
INJ LASIX 40 mg /IV/BD
INJ ZOFER 4 mg IV/BD
INJ TRAMADOL 1 amp 100ml NS/ IV/TID
TAB UDILIV 300 mg PO/TID
TAB RANTAC 150 mg PO/BD
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