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.
A 23year old male patient farmer by occupation came to casualty with c/o : generalised weakness since 1week.
HOPI : Patient was apparently asymptomatic 1week back, then he gradually developed generalised weakness.
PAST HISTORY : Patient is not a k/c/o HTN,
h/o DM, tb, epilepsy, cad, asthma.
-H/O Solitary left kidney only since birth.
Patient underwent 3 dialysis in the past.
PERSONAL HISTORY : Diet - mixed, Sleep - adequate, Appetite - normal, Bowel and bladder movements - normal.
GENERAL EXAMINATION :
Patient is conscious, coherent, cooperative
well oriented to time and place.
No pallor, icterus, cyanosis, lymphadenopathy.
VITALS:
Temp- 98.6F
PR - 92bpm
Spo2 - 99%
RR - 16cpm
GRBS - 110mg/dl
Blood Pressure - 110/80mmhg
CVS - S1,S2+ no murmurs
RS - BAE+, nvbs heard
no wheeze, no crepts
P/A - Soft, non tender, organomegaly
Bowel sounds +
CNS - NFND
INVESTIGATIONS
PROVISIONAL DIAGNOSIS :
Chronic renal failure with left single kidney.
TREATMENT :
1) FLUID AND SALT RESTRICTIOB
2)TAB NICARDIA 20MG PO/BD
3)TAB NODOSIS 500 PO/BD
4)TAB OROFER- XT PO/BD
5)CAP BIO- D3 PO/BD
6)INJ ERYTHROPOIETIN 5000 IU/SC/WEEKLY ONCE
7)TAB SHELCAL 500MG PO/BD.
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