GENERAL MEDICINE Pre Renal AKI

ACUTE KIDNEY INJURY

Hello all this is G chaitanya,a eighth semester student.This E Log depicts the patient centered approach to learning.

This is an online E Logbook recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent

Date of admission:- 30/09/2023 
A 65 year old female came to OPD with -

CHIEF COMPLAINTS-
fever ,vomitings,cough since 5 days.

HOPI-

Patient was apparently asymptomatic 5 days back then she developed fever , which is high grade associated with chills and rigor, continuous type, no diurnal variation, associated with vomitings, cold, cough, loss of appetite, generalised body pains.
H/o vomitings since 5 days , sudden in onset, food as content, non bilious, non projectile, non blood stained, 4 to 5 episodes.
H/o cough since 5 days , which is productive whitish sputum thick consistency.
H/o chest pain left sided associated with SOB grade - 2 according to mMRC .
H/o right hypochondriac abdominal pain since 5 days.
No H/o loose stools, burning micturition.

PAST HISTORY-

K/C/O HTN since 2 years and is on medication (unknown)
Not k/c/o DM, TB, asthma, epilepsy, thyroid disorders.

PERSONAL HISTORY- 

Diet- mixed 

Appetite- normal 

Sleep- adequate 

Bowel and bladder movements- regular 

No known allergies 

Addictions-  used to consume pan one or twice daily but stopped from past 4 months.

DAILY ROUTINE

She'll wake up around 5:00am and completes her household chores and then have breakfast at 10am and goes for work then will have ,lunch at 2:00pm and comes back from work around 5pm and will have tea .Then she'll have her dinner at 8pm .Mostly all the three times she'll have rice .Then she'll go to bed by 10pm

FAMILY HISTORY- not significant 


GENERAL EXAMINATION-

patient is conscious, coherent, cooperative. Well oriented to time , place and person, moderately built and moderately nourished 

VITALS

BP- 130/80 mmHg

PR- 92 bpm

RR- 18 cpm

TEMP- 98.2 F

PRESENCE OF PALLOR.

NO SIGNS of ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, OEDEMA.




SYSTEMIC EXAMINATION-

1) CVS- S1, S2 heard, no murmurs.

2) RS- BAE present, NVBS 

3) PER ABDOMEN- diffuse tenderness 

 no organomegaly 

4) CNS:

Higher mental functions - intact

Cranial nerves - intact

Motor examination - normal  

Sensory examination:Normal

No meningeal signs

INVESTIGATIONS-

CHEST X-RAY-



ECG

USG





PROVISIONAL DIAGNOSIS::-

PYREXIA UNDER EVALUATION WITH 

LEFT LOWER ZONE COLLAPSE.

PRE RENAL ACUTE KIDNEY INJURY.

HYPOKALEMIA SECONDARY TO GE , KNOWN CASE OF HTN SINCE 2 YEARS.

TREATMENT::

30/9/23

1. INJ. PAN 40MG IV/OD

2. INJ. ZOFER 4MG IV /TID

3. IV. FLUIDS - 2NS @ 75ML/HR  - 1 RL 

4. INJ. NEOMOL 1GM IV/SOS

5. TAB. DOLO 650MG PO/TID

6.  SYP. ASCORIL-LS 15ML/PO/TID

1/10/23

1.INJ. PAN 40MG IV/OD

2. INJ. ZOFER 4MG IV/TID

3. IV. FLUIDS - 2NS @ 75ML/HR  - 1 RL 

4. INJ. NEOMOL 1GM IV/SOS

5.INJ.MONOCEF -1GM IV/BD

6. TAB. DOLO 650MG PO/TID

7.  SYP. ASCORIL-LS 15ML/PO/TID.

2/10/23

1.INJ. PAN 40MG IV/OD

2. INJ. ZOFER 4MG IV/TID

3. IV. FLUIDS - 2NS @ 75ML/HR - 1 RL 

4. INJ. NEOMOL 1GM IV/SOS

5.INJ.KCL 2  AMPULES IN 500ML NS IV SLOWLY OVER 5-6HOURS

6.TAB.PCM 650MG PO/TID

7.TAB.AMLODIPINE 5MG PO/OD

8.SYP.ASCORIL-LS 15ML/PO/TID.

9.INJ.CIPROFLOXACIN 200MG IV/BD

10.TAB.SPORLAC DS PO/TID

3/10/23

1.INJ. PAN 40MG IV/OD

2. INJ. ZOFER 4MG IV/TID

3. IV. FLUIDS - 2NS @ 75ML/HR - 1 RL 

4. INJ. PCM 1GM IV/SOS

5.INJ.REDOTRIL  100MG PO/BD

6.TAB.PCM 650MG PO/TID

7.TAB.AMLODIPINE 5MG PO/OD

8.SYP.ASCORIL-LS 15ML/PO/TID.

9.INJ.CIPROFLOXACIN 200MG IV/BD

10.TAB.SPORLAC DS PO/TID

11.INJ.METROGYL 500MG IV/TID

4/10/23

1.INJ. PAN 40MG IV/OD

2. INJ. ZOFER 4MG IV/TID

3. IV. FLUIDS - 2NS @ 75ML/HR - 1 RL 

4. INJ. PCM 1GM IV/SOS

5.INJ.REDOTRIL 100MG PO/BD

6.TAB.PCM 650MG PO/TID

7.TAB.AMLODIPINE 5MG PO/OD

8.SYP.ASCORIL-LS 15ML/PO/TID.

9.INJ.CIPROFLOXACIN 200MG IV/BD

10.TAB.SPORLAC DS PO/TID

11.INJ.METROGYL 500MG IV/TID

5/10/23

1.INJ. PAN 40MG IV/OD

2. INJ. ZOFER 4MG IV/TID

3. IV. FLUIDS - 2NS @ 75ML/HR - 1 RL 

4. INJ. PCM 1GM IV/SOS

5.INJ.REDOTRIL 100MG PO/BD

6.TAB.PCM 650MG PO/TID

7.TAB.AMLODIPINE 5MG PO/OD

8.SYP.ASCORIL-LS 15ML/PO/TID.

9.INJ.CIPROFLOXACIN 200MG IV/BD

10.TAB.SPORLAC DS PO/TID

11.INJ.METROGYL 500MG IV/TID

1.INJ. PAN 40MG IV/OD

2. INJ. ZOFER 4MG IV/TID

3. IV. FLUIDS - 2NS @ 75ML/HR - 1 RL 

4. INJ. PCM 1GM IV/SOS

5.INJ.REDOTRIL 100MG PO/BD

6.TAB.PCM 650MG PO/TID

7.TAB.AMLODIPINE 5MG PO/OD

8.SYP.ASCORIL-LS 15ML/PO/TID.

9.INJ.CIPROFLOXACIN 200MG IV/BD

10.TAB.SPORLAC DS PO/TID

11.INJ.METROGYL 500MG IV/TID


6/10/23

1.INJ. PAN 40MG IV/OD

2. INJ. ZOFER 4MG IV/TID

3. IV. FLUIDS - 2NS @ 75ML/HR - 1 RL 

4. INJ. PCM 1GM IV/SOS

5.TAB.AMLODIPINE 5MG PO/OD

6.TAB.PCM 650MG PO/QPD

7.SYP.ASCORIL-LS 15ML/PO/TID.

8.INJ.DOXYCYCLINE 100MG IV/BD

9.TAB.SPORLAC DS PO/TID

10.INJ.SODIUM BICARBONATE 25MCG IV START

7/10/23

1.IV. FLUIDS - 2NS @ 75ML/HR - 1 RL

2.INJ.DOXYCYCLINE 100MG IV/BD

3.INJ.FALCIGO 120MG IV 

4.INJ.SODIUM BICARBONATE 50MCG IV STAT 50 MCG IN 500ML NS OVER 8HOURS

5.INJ.PCM 1G IV/SOS

6.INJ.ZOFER 4MG IV/SOS

7.TAB. PCM 650MG PO/QID

8.TAB.NODOSIS 500MG PO/QID

9.TAB.AMLODIPINE 5MG PO/OD

10.INJ.PAN40MG IV/OD

8/10/23

1.IV. FLUIDS - 2NS @ 75ML/HR - 1 RL

2.INJ.DOXYCYCLINE 100MG IV/BD

3.INJ.FALCIGO 120MG IV 

4..INJ.PCM 1G IV/SOS

5.INJ.ZOFER 4MG IV/SOS

6.TAB. PCM 650MG PO/QID

7.INJ.PAN40MG IV/OD

8.TAB.NODOSIS 500MG PO/QID

9.TAB.AMLODIPINE 5MG PO/OD

9/10/23

1.IV. FLUIDS - 2NS @ 75ML/HR - 1 RL

2.INJ.DOXYCYCLINE 100MG IV/BD

3.INJ.METHYLPREDISOLONE 1GM IV/OD

4.INJ.PAN40MG IV/OD

5.TAB.NODOSIS 500MG PO/QID

6.INJ.LASIX 20MG IV/BD

7.INJ.KCL 2AMPULES IN 500ML NS IV SLOWLY OVER 5-6HOURS

10/10/23

1..IV FLUIDS NS @30 ml/hr

2.INJ.DOXYCYCLINE 100MG IV/BD

3.INJ.METHYLPREDISOLONE 1GM IV/OD

4.INJ.PAN40MG IV/OD

5.TAB.NODOSIS 500MG PO/QID

6.INJ.LASIX 20MG IV/BD

7.PCM 650 MGMG PO/QID

11/10/23

1.IV. FLUIDS - 2NS @ 75ML/HR - 1 RL

2.INJ.DOXYCYCLINE 100MG IV/BD

3.INJ.METHYLPREDISOLONE 1GM IV/OD

4.INJ.PAN40MG IV/OD

5.TAB.NODOSIS 500MG PO/QID

6.INJ.LASIX 20MG IV/BD

7.SYP.ASCORIL-LS 10ML/PO/TID.


12/10/23

1.IV. FLUIDS - 2NS @ 75ML/HR - 1 RL

2.INJ.DOXYCYCLINE 100MG IV/BD

3.INJ.METHYLPREDISOLONE 1GM IV/OD

4.INJ.PAN40MG IV/OD

5.TAB.NODOSIS 500MG PO/QID

6.INJ.LASIX 20MG IV/BD

7.SYP.ASCORIL-LS 10ML/PO/TID.


Comments

Post a Comment

Popular posts from this blog

A 13 yr Male with Redness of eyes,Fever, Burning micturition and swelling of cheeks

Image
A 13yr old male  who is student brought by parents with complaints of Redness of eyes since the 5days Fever since 4days Burning micturition since 4days  History of present Illness: Patient was apparently asymptomatic 5days   back after   which he developed Redness of eyes,followed by Fever which is high grade  insidious onset, gradually progressive associated with burning micturition. H/o yellowish discoloration of eyes 3days H/o swelling in both cheeks since 2days  H/o pain and difficulty in flexing left knee since 2days associated with progressive swelling No H/o recent travel  No H/o  similar complaints in the past  PAST HISTORY  N/k/c/o DM, Hypertension,  TB, Epilepsy,CVD, Asthama,Thyroid disorders PERSONAL HISTORY Single Student Diet :Mixed Appetite: Lost Sleep: adequate Bowel and bladder regular Addictions No  No known Allergies  GENERAL EXAMINATION Pt is conscious coherent and cooperative  Icterus present No  pallor, cyanosis, clubbing generalized lymphadenopathy, edema  Vitals
Read more

Acute pancreatitis . General medicine Assignment

Image
This is G.Chaitanya  , 8 th sem student .This Elog depicts patient centred approach to learning. 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 comprehencing clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. October 27, 2023 A 40 yr old male patient , resident of miryalguda , who is daily wage labourer by occupation came to O
Read more

54 yr old male DIABETIC FOOT

Image
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 29 NOVEMBER 2023 A 54 yr old male Patient came to causality with complaints of Fever since 5 days SOB since 5 days Vomiting for 3 days History of present Illness::-  The patient was apparently asymptomatic 5 days back then he developed fever, which is of high grade associated with chills and rigors.not relieved on taking medication . He complaints of Shortness of breath since 5 days, which is grade lll  No orthopnea and paroxysmal nocturnal dyysuria. Also presents with vomitings since 3 days,2-3 episodes of per day which is non bilious, non blood stained , watery, episodes. Th
Read more