A 62 yr old female with anuria
This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.
Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
This E-blog also reflects my patient's centred online learning portfolio.
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 a diagnosis and treatment plan.
C/o
N/K/C/O DM,BA,TB,CVD
GENERAL EXAMINATION
No pallor, No icterus, No Cyanosis, No Lymphadenopathy, No Edema
VITALS
Temperature -98F
Pulse rate- 98bpm
Blood pressure-90/60mm hg
Respiratory rate -24cpm
Spo2-96% on 4 lit of O2 on T piece
SYSTEMATIC EXAMINATION:
PER ABDOMEN:Soft, non tender
No guarding, No rigidity
Bowel sounds present
CARDIOVASCULAR SYSTEM:
S1,S2 heard, NO Murmurs
RESPIRATORY SYSTEM:
BAE present,NVBS
CENTRAL NERVOUS SYSTEM:
NAD
PROVISIONAL DIAGNOSIS-AKI ON CKD
TREATMENT
1.INJ MONOCEF 1gm IV BD
2.INJ PAN 40mg IV OD
3.NEBULISATION WITH DUOLIN AND BUDECORT 8th hourly
4.TAB NODOSIS 500mgPO BD
5.TAB SHELCAL 500mg PO OD
6.TAB BIO D3 weekly once
7.INJ EPO 4000IU weekly once
8.INJ LASIX 20 mg IV BD
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