38 yrs old male

15/11/2021

Sai prasanna.k

3rd sem

This is an 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 patient's clinical problems with collective current best evidence based inputs.This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment

Cheif complaints:

Patient came with the cheif complaints of loss of appetite, decrease in sleep,nausea since 10days, shortness of breath,loin pain since 6days.
Patient was apparently 6mnts back decrease in appetite, nausea,fever(on and off), decreased urine out put

Present illness:

USG abdomen and pelvis done 
Showed hydronephrosis with uterine calculi right-13mm left-23mm

Personal history:

Married
Appetite:lost since 10 days
Bowels:regular
Micturation:normal
Addictions:alcohol consumption occasionally

Family history:

No significant family history

Physical examination:

General examination:

Pallor:+ve 
Icterus:no
Cyanosis:no
Clubbing:no
Lymphonedopathy:no
Odema:no

Vitals
Pulse rate:86bpm/min
Respiratory rate:12cpm/min
Bp:80/50mmhg
Slow:99%
GRBS:124mg%

Systemic examination:

CVS:

S1,S2 are present
No murmurs

CNS:

Reflexes
                     Right.                   Left

Biceps.            2+.                          2+
Triceps.             +.                          + 
Supinator.          +.                          +
Knee.                    2+.                       2+ 
Ankle.                    +.                          +

Provision diagnosis:

Acute kidney injury on CKD secondary to post renal obstruction with uterine calculi,hydrouteronephritis URSL with stenting done

Investigations:









Treatment:
On 9







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