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A 50 year old female patient e log

E-LOG GENERAL MEDICINE
Hi, This is K.Srinija , a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them

★ CASE SCENARIO

A 50 YR OLD FEMALE WITH ANURIA

★ CHIEF COMPLAINTS 

Anuria since 3 days
Fever with chills since 3 days
SOB grade 3 since 3 days
Throat pain with difficulty in swallowing since 1 week

★HISTORY OF PRESENT ILLNESS

-Apparently pt was asymptomatic 1 week ago
Then she developed few throat ulcers which made her difficult to swallow even water. 
-She got treated for it in a local hospital but it did not get cured. 
Due to those ulcers, she couldn't even drink nor eat. 
-Since 3 days, she developed fever with chills, anuria, SOB
Yesterday morning, they visited a govt hospital in suryapet, where they stayed till evening just to know that she was suffering with renal failure and hence the hospital cannot afford to keep them anymore. 
-Then they had to immediately shift her to a private hospital in suryapet, who eventually rejected to admit her because of the same unethical reason. 
Later, yesterday night by 8pm they reached our hospital. 


★ PAST HISTORY
- N/k/c/o DM , HTN , epilepsy. Asthana , TB 

★ FAMILY HISTORY
-Nil significant

★ PERSONAL HISTORY
-Sleep and appetite inadequate
-Mixed diet
-Bowel regular
-Micturition - anuria since 3 days
-No addictions and allergies


★ GENERAL EXAMINATION
- No - pallor, icterus,cyanosis, lymphadenopathy,clubbing, oedema of foot 
-Temp: 101 F
- PR : 120/min
-RR: 24/ min
-BP : 70/50
- SPo2 : 94% at RT
-GRBS : 94mg%

★ SYSTEMIC EXAMINATION
— CVS
- No thrills , murmurs
- S1,SE heard

— RS
-Dyspnea : yes
- wheeze : no
- vesicular breath sounds , trachea : central

—  ABDOMEN
- shape of abdomen : obese

— CNS
- patient : conscious
- speech is normal
- No signs of meningeal irritation
- High motor functions intact 

★ PROVISIONAL DIAGNOSIS

- AKI


★ INVESTIGATIONS 

17/8/22



18/8/22




★ Rx
Emergency hemodialysis done yesterday night







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