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