General medicine 

                                      125 Afrin 
                                    131 Durga Sri. (3rd sem)
                 

This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 

 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.

Overview :

    patient came to hospital on 8th October 2021 when he came to know he has B/L renal calculi in USG abdomen &pelvis for which he underwent nephrostomy on 13/10/21 &left URSL with DJ stenting on 20/10/21 and then discharged and suggested to follow Up next month. 

         After discharge there is no improvement in his condition, so they suggested with 3 sessions of dialysis &Right URSL after a month but due to failure of dialysis through IJV on third session he was still in the hospital. 


* 38 year old male came to casualty with loss of appetite ,decreased sleep, nausea since 10 days and shortness of breath ,loin pain since 6 days.

Chief complaints : 

   Patient has decreased appetite, nausea, fever (on and off)  , decreased urine output 6 months back. 
Fever( on &off)  - low grade intermittent not associated with chills and rigor.
Burning micturation.

General examination : 

Pallor -present 

No icterus

No cyanosis 

No clubbing of fingers or toes 

No lymphadenopathy 

No edema 

No malnutrition 

No dehydration 

Afebrile temperature 

Pulse rate - 86b/m

Respiration rate - 12 cpm 

Bp - 80/50 mm Hg 

Spo2 -99%

GRBS -124mg%

Systemic examination : 

Cardiovascular system :

S1,S2- heard 

No added sounds 

Respiratory system: 

Normal vesicular breath sounds heard. 

Trachea centrally present 

Abdomen : 

Tenderness -diffuse(mild )

Shape of abdomen -scaphoid 

Central nervous system : 

Conscious coherent cooerative

Investigations : 

8/11/21 

Hemogram :



Hemogram :


Serum creatinine:


Serum electrolytes :


Complete urine examination : 


Blood urea: 


11/11/21


RFT : 



Hemogram : 



14/11/21

Hemogram : 


RFT :


ECG : 





Provisional diagnosis : 

AKI on CKD secondary to post renal

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