Case history-1

28 February,2022

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 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 COMPLAINT:
17 Year old female patient presented to the OPD with a chief complaint of pain in the left 
Lower back  and complaint of lumps over the left back region.

HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 month ago, she underwent left Percutaneous Nephrostomy for pyelonephritis
Pt is on CIC and bladder wash

HISTORY OF PAST ILLNESS:
No history of  Diabetes mellitus, Hypertension ,Thyroid, Asthma epilepsy

PERSONAL HISTORY:
Diet - mixed
Appetite - Normal
Bowels and urine - Regular
Sleep - Adequate
No addiction
No allergies

FAMILY HISTORY:
No similar history in the family

GENERAL EXAMINATION:
- Patient is conscious,coherent and cooperative at the time of joining

-No pallor

-No icterus

-No lymphadenopathy

-No cyanosis

-No clubbing of finger

-No oedema of feet


Vitals:
Temperature - afebrile
Pulse rate - 78 bpm
Respiration rate -  16 cpm
BP - 110/70 mmHg
Spo - 98%

SYSTEMIC  EXAMINATION:
  
▪️CVS

- no thrills

- no cardiac murmurs

S1 & S2 sounds are heard

▪️RESPIRATORY SYSTEM

-BAE present

▪️CNS

-HMF intact

INVESTIGATIONS:
Urea-4.3
Cr-0.9
VA-2.4
Ca+-10.0
P+-4.8
Na+-1.41
K+-3.8
Cl+-107

 X-ray
Diagnosis:
Left ureteric calculi

Treatment:
T.Oflox 200mg/Po/BD
T.pan 40mg /Po/OD
T.Pcm 650mg/Po/SOS
Syp.CITRALKA B6 / TID



 



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