31-05-2024
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
EMR SUMMARY:
Age/Gender: 65 Years/Male
Address:
Discharge Type: Relieved
Admission Date: 29/05/2024 06:28 PM
Diagnosis:
ACUTE ON CHRONIC KIDNEY DISEASE RIGHT LOWER LIMB CELLULITIS
4 SESSIONS HAEMODIALYSIS DONE
Case History and Clinical Findings
C/O B/L LOWER LIMB SWELLING SINCE 5 DAYS H/O FEVER SINCE 5 DAYS
HOPI:
PT WAS APPARENTLY ALRIGHT 5 DAYS AGO AND THEN DEVELOPED SWELLING OF LOWER LIMBS WITH BLISTERS 3 DAYS AGO
NO H/O VOMITING, GIDDINESS, LOOSE STOOLS
NO H/O BURNING MICTURITION, DECREASED URINE OUTPUT NO H/O CHEST PAIN AND TIGHTNESS
NO H/O SOB, ORTHOPNEA, PND PAST HISTORY:
NOT A K/C/O HTN, DM, CAD, CVA, ASTHMA, EPILEPSY, TB, THYROID DISORDERS PERSONAL HISTORY
DIET: MIXED APPETITE: NORMAL
BOWEL AND BLADDER MOVEMENTS: REGULAR. NO KNOWN ALLERGIES AND ADDICTIONS.
FAMILY HISTORY: NOT SIGNIFICANT. GENERAL EXAMINATION:
PATIENT IS CONSCIOUS, COHERENT AND COOPERATIVE.
NO PALLOR, ICTERUS, CYANOSIS, GENERALISED LYPHADENOPATHY, PEDAL EDEMA PRESENT
TEMP: 98.1 F
PR: 86 BPM
RR: 18 CPM
BP: 90/60MMHG SPO2: 98% @ RA GRBS- 179
SYSTEMIC EXAMINATION:
CVS: S1 S2 HEARD. NO MURMURS RS: TRACHEA- CENTRAL. BAE+
P/A- SOFT, NON- TENDER. BOWEL SOUNDS HEARD. CNS: NO FOCAL NEUROLOGICAL DEFECTS. REFLEXES-RT LT
BICEPS + + TRICEPS + + SUPINATOR + + KNEE - -
ANKLE + -
COURSE IN THE HOSPITAL:
GENERAL SURGERY OPINION WAS TAKEN I/V/O RIGHT LOWER LIMB CELLULITIS AND REGULAR DRESSINGS Were Done FOR THE SAME
Investigation
CBP HB TC N L E M B PLT SMEAR RFT UR CR UA CA+2 P NA+ K+ CL- HIV HBSAG
HCV Name Value Name Value RFT 30-05-2024 01:13:AM UREA59 mg/dl CREATININE3.5 mg/dl URIC ACID6.2 mmol/L CALCIUM10.1 mg/dl PHOSPHOROUS4.6 mg/dl SODIUM148 mmol/L POTASSIUM3.8 mmol/L. CHLORIDE106 mmol/L
RFT 30-05-2024 10:58:PM UREA63 mg/dl CREATININE3.5 mg/dl URIC ACID7.0 mmol/L CALCIUM10.0 mg/dl PHOSPHOROUS4.7 mg/dl SODIUM145 mmol/L POTASSIUM3.7 mmol/L. CHLORIDE106 mmol/L
Treatment Given (Enter only Generic Name)
1) IV FLUIDS NS @ 50ML/HR
2) INJ.PIPTAZ 2.25 GM IV/TID
3)INJ.CLINDAMYCIN 600MG IV/BD
4)INJ.LASIX 40MG IV/BD
5)INJ.PAN 40MG IV/OD
6)TAB.CHYMEROL FORTE PO/TID.
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