A 15 yr old male


This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians signed informed consent.

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve the patients  clinical problem with current best evidence based input.

This Elog also reflects my patient centered online learning portfolio.
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.


A 15 yr old male ,studying 9 th class came to the casuality with C/O SOB( grade 2 - 3 ) since yesterday ,orthopnea + 

 HOPI :

Pt was apparently asymptomatic 1 month back ,pt complains of vomitings 2 - 3 episodes daily associated with food particles not associated with blood ,for around 1 month 

H/O fever 1 month back associated with chills ,relieved with medication by 2 days 

InIncidentally patient found to have urea 62 mg/dl

Creatinine 8.3 went to Hyderabad within 1 day urea has raised to 135mg/dl and creatinine 10.7 

And started him on dialysis .5 sessions of HD done and USG abdomen showing B/L kidneys size of 8.1 cms Grade 3 RPD changes .Since then he was on hemodialysis pt C/O SOB since yesterday evening aggravating on supine position Grade 2 - 3 ,not associated with PND 

C/O chest pain ,dragging type only during episode of sob 

No C/O palpitations ,syncope attack 

No C/O decreased urine output ,pedal edema ,facial puffiness 

           

           Previous reports : 




Past History: 

Hypertensive since 1 month and is on Tab.AMLONG 5 mg 

History of 3 transfusions 1 month back 

Not a K/C/O DM ,Asthma ,epilepsy ,thyroid disorders 



Family History :

No H/O renal problems in their whole family.

His paternal grandfather is diabetic and hypertensive

Personal History:

Diet - mixed 

Appetite - normal 

Sleep - adequate 

Bowel movements : regular 

Bladder movements : regular 

No history of alcohol consumption or smoking history 

 

General Examination:

Patient is conscious, coherent , cooperative

Pallor -present 

Icterus -absent 

Clubbing-absent 

Cyanosis -absent 

Generalised Lymphadenopathy-absent 

Pedal Edema -absent 

Vitals : 

Temperature : afebrile 

Pulse rate : 96 bpm

Respiratory rate : 24 cycles /min 

BP : 140/100 mm of Hg 

SpO2 : 86 % at Room air .

GRBS : 121 mg%





Systemic Examination: 

CVS: S1,S2 heard no murmurs

CNS: normal

RS :

Bilateral Air Entry - present 

Bilateral crepitations heard at IAA and ISA.              

No wheeze .

PA: 

Soft ,non tender 

Bowel sounds + 

CNS:

NAD 

Blood group : A positive 


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