General medicine elog

 Hi, I am Satyanarayana 3rd sem medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio. 

A female patient of  30 yrs old came to casualty with severe abdomen epigastrium pain and low grade fever and low urine output

 CHIEF COMPLAINTS: 

12 yrs ago she developed Hypertension during pregnancy @ at the time of labour and started on anti HTN and stopped 3 to 4 months later 

 7 months ago she got oedema and not relieved by medication and after months oedema increased and treated with CKD on MHD 

3 months ago started on MHD 

HISTORY OF PRESENT ILLNESS 

On  2of June came to causality with abdomen abdomen epigastrium pain and low urine output 

She got low grade fever and  necessary investigations were done 

HISTORY OF PAST ILLNESS 

Patient was found to have moderate to severe pericardial effusion 

On blood examination pseudomonas isolated 

She was treated with Dialysis weekly once 

TREATMENT HISTORY:

Diabetes :no 

Hypertension : Present

Asthma: no 

Tuberculosis:no 

Surgeries:no 

Blood transfusion: no 

PERSONAL HISTORY:

Micturition : normal 

Bowels : regular 

Apetite: normal

FAMILY HISTORY:

There is no family History 

GENERAL EXAMINATION:

Vital signs: 

Temperature: 98.6F  

Pulse rate: 98/min 

Respiratory rate 18 /min 

No icterus 

No pallor 

No clubbing of fingers 

Oedema is present 

Patient is unconscious 

PROVISIONAL DIAGNOSIS: 

CKD ON MHD 

Investigations ordered: 

Uremic pericarditis and bilateral pleural effusion

ULTRASOUND REPORT:

Investigations: 

TREATMENT GIVEN:

Injection piptaz 2.25 gm IV 

Injection pan 40 mg  IV

Injection Zofer 4 mg IV

Injection Tramadol IV 

Tab Telma 40 mg

Tab Nodosis 500 mg

Tab metxl  12.5 mg 

Tab chellal 500 mg 

WHERE IS THE ANATOMICAL LOCATION OF PATIENTS PROBLEM?? 

It is a clinical syndrome characterized by chills and fever , flank pain,and constitutional symptoms caused by bacterial invasion of the kidney . Micro anatomical location is RENAL PELVIS in kidney

Why is the patient having this problem? (related to microanatomical pathogenesis as well as macro-social environmental events influencing

Because both the kidneys are damaged and got failure ... ? 

WHAT ARE WE DOING ABOUT IT?? (pharmacological and non pharmacological interventions)

Pharmacological interventions

Inj-Piptaz 4.5gms /IV

Inj-PAN 40 mg/Iv

Inj-zoffer 4mg/Iv

Inj-Neomal/IV if temperature is more

Non pharmacological interventions

TPR graphic sheet 

Ultrasound scanning

NCCT-KUB(PLAIN)

2D Echo

ECG