MHD
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.
40 year old male, daily labourer by occupation came to casuality with chief complaint of shortness of breath,reduced urine output,bilateral pedal edema (pitting type) since 3 days.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 3 days back and then she noticeddecreased urine output and bilateral pitting edema.
And from this morning she has sob grade 1
History of Past illness :
K/c/o CKD on MHD.
Recurrent UTI
TREATMENT H/O:
K/C/O DM since 1 yr on INSULIN
DIAGNOSIS:
CKD ON MHD
SEPSIS secondary to UTI
TREATMENT:
1.INJ.LASIX 40 mg IV/BD
2.INJ.PIPTAZ 4.5g STAT-2.25 g BD
3.INJ.PAN 40mg IV/OD
4.INJ.IRON SUCROSE 1AMP IN 100 ml NS
5.INJ.NODOSIS 500mg PO/OD
6.CAP.BIO D3 PO/OD
7.T.OTOFER XT PO/OD
8.T.ECOSPRIN 180 mg PO/HS
9.T.CLOPI 75 mg PO/HS
10.SALT(<2g) FLUID(<2.5 lts)
12.T.MET XL PO/OD
1 pack of PRBS was transfused
