Skip to main content

60 YEAR OLD FEMALE WITH AKI SECONDARY TO CONSUMPTION OF UNKNOWN COMPOUND

 This is an a 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

CHIEF COMPLIANTS

vomitings since evening 4hrs - 3episodes 
Loose stools 2 episodes

HOPI
Patient was apparently asymptomatic 4hours back then developed vomitings 3 episodes food as content non bilious non blood stained non projectile 
No h/o outside food intake
No h/o fever 
No h/o abdominal pain 
No sob 

PAST HISTORY
Not a k/c/o htn DM epilepsy Tb asthma

TREATMENT HISTORY
No

PERSONAL HISTORY
appetite normal 
Diet mixed
Bowel and bladder regular
Addictions tobacco snuff

FAMILY HISTORY
no

GENERAL EXAMINATION
 patient is conscious coherent and cooperative

No pallor icterus clubbing cyanosis lymphadenopathy

Vitals 
Temp 98.4F
PR 86 bpm
RR 18  cpm
GRBS 160mg%

SYSTEMIC EXAMINATION 
CVS S1 S2 + no murmurs 
RESPIRATORY 
Trachea central 
Normal vesicular breath sounds
ABDOMEN no tenderness
                    No bruits
                    Liver not palpable
                    Spleen not palpable
                    
CNS. Reflexes 
                      Right   left

Biceps.          +2.       +2

Triceps.         +2.       +2

Supinator.      +2.       +2

Knee.              +2.        +2

Ankle.             +2.        +2

INVESTIGATIONS
05/04/23

HEMOGRAM





LFT
RFT
                                                            
ABG


05/04/23 morning 8 00 AM 



CUE

ULTRASOUND
ECG



Comments

Post a Comment

Popular posts from this blog

Self assessment

 K.pavan  ROLLNO. 77 Did sleep study in my UG , learned how respiration (spo2) changes accordingly with sleep .Thus awoken my interest in medicine. And started asking how ? Why? For everything  During UNIT duties  https://167pavankotha.blogspot.com/2023/04/45f-with-bl-knee-pains.html  1) what is the cause for her morning stiffness  2)  is occupation the reason for her symptoms? 3) what is the preventive aspect of such disease? https://167pavankotha.blogspot.com/2023/03/this-is-online-e-log-book-to-discuss.html 1) what is the cause for his ascites ? 2) can his lifestyle be one of the cause for his condition ? https://167pavankotha.blogspot.com/2023/03/67m-dementia-with-headache.html 1) what are the differentials for unilateral head aches ? 2) what is the cause for his unilateral headache? https://167pavankotha.blogspot.com/2023/04/chief-compliants-vomitings-since.html 1) how do you confirm that his symptoms are due to the consumption of an unknown compo...
Post a Comment
Read more

80 year old female with sob

  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 solveb 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. CASE: This is a case of a 80 year old female with complaints of  1. vomitings (4-5 episodes) 2. abdominal discomfort since 08/04/2023. HISTORY OF PRESENTING ILLNESS: Patient was apparently asymptomatic 2 hours ago.She then had 4-5 episodes of vomiting which contained of food particles,non bile stained,not foul smelling and not blood stained.It is associated with giddiness and abdominal discomfort. No complaints of fever,loose stools,shortness of breath,chest pain,ortho...
Post a Comment
Read more

77M ASCITES(?Non portal hypertensive?SBP H/O EMPYEMA ?TB used ATT 6months

  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" 77 year old male daily wage labourer by occupation president of narayanapuram complaints of abdominal dtension since 3 days  History of presenting illness: Patient was apparently a symptomatic until 3 days ago then he had complaints of sudden on set of abdominal distention accompined with twisting type of pain; Dyspnea, constipation decreased urine output, painful defecation aggravated after having food No complaints of fever headache giddiness No complaints of bilateral peda...
Post a Comment
Read more