45 Goli Shreya ( 3 rd Sem)
This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed 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 patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome
Case Scenerio
A 75 year old male patient came to casuality in unresponsive state since 1 hour.Patient was having fever since 10 days
History of Present illness
HOPI-patient was apparently -
- asymptomatic 10 days back then he had insidious onset of fever
- low grade intermittent ,releived with medication,
- not associated with any chills and Rigors.
Yesterday morning he woke up,done his routine works and was normal till evening ,went to sleep and they tried to wake him up,as the patient was unresponsive they brought him to our hospital.
4 months back patient wide was demised ,from then he was not interacting actively with his family members and having excessive sleep
Patient attendees are saying that patient had h/o wt loss
Patient had h/o left sided scrotal swelling since 6 years
Past illness-
No h/o diabetes ,HTN,Asthama ,TB and epilepsy
Present history-
Appetite -decreased since two months
Sleep -excess
Bowel and bladder movements -normal nd regular
Addictions -none
On Examination
E1,V1,M1
BP-140 systolic
PR-42/min,regularly,irregular
RR-BLAE present
CVS :
S1S2 HEARD
no thrills no murmurs
Per abdomen:
Non distended
Diffuse tenderness absent
Guarding and rigidity absent
CNS-
Right Left
Tone UL. Hyper Hypo
LL. Hypo Hypo
Power UL - -
LL - -
Reflexes-
B- ++ ++
T- ++ ++
S ++ ++
K- + -
A- - -
P- extensor extensor
Diagnosis- ?
Uremic encephalopathy with AKI on CKD
Comments
Post a Comment