GENERAL MEDICINE E-lOG

31 YEAR OLD MALE WITH POST RENAL TRANSPLANTATION

ARUSHI KUMARI
151 
 
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 .

A 31 year old male , K/C/O CKD stage 5 with renal transplantation done came for regular check up .

History of Presenting Illness
-  Patient was apparently asymptomatic 5 years back .
* Sequence of events 
- In 2017 , patient started feeling generalised weakness along with blood in vomiting for which he consulted local doctor . 
- The doctor asked for CBC which showed he is anaemic .
- Till 2018 he and on and off symptoms of the same .

** In 2019 he presented following symptoms :
- Fever 101-102 F which was continuous , high grade associated with chill
- Chest pain 
- SOB
- severe cough with blood
- He was admitted in the government hospital where he was diagnosed with pleural effusion .
- 2 episodes of thoracocentesis was done and was discharged from there .
- Then in the same year he came to our hospital and was admitted . He stayed for a period of 7 months .
- 3-4 episodes of thoracocentesis was done here during that hospital stay .
- During the stay period , one morning all of a sudden he developed severe shortness of breath and had severe cough with blood in sputum .
- His SpO2 dropped to 30 per cent . So he Nebulised but no improvement in SpO2 was noted .
- So he was shifted on BiPAP . Still his SpO2 raised only upto 80 per cent .
- So finally he was put in Ventilator for 3 days after which he became normal .
- Afterwards he was shifted on O2 for the rest month of stay in hospital ( rest 3-4 months ) 
- He also had several other symptoms pointing to renal dysfunction .
He complained of following symptoms : 
# vomiting 
# severe weakness 
# patient was unable to walk ( the doctor   said he had uric acid deposition in his joint ) 
# decreased urine output 
# frequent motions 
He was found to have deranged Renal function tests.
-He was on dialysis during those 7 month stay ( 3-4 dialysis per week ) 
And then he was discharged .
 - After going back to his hometown , there also he was on regular dialysis for a period of 9 months ( 3-4 episodes per week ) .

** 2021 
 In February 2021 he again came to our hospital and was admitted .
- For 2 Months he was on dialysis weekly twice .
- Then on 4th April 2021 he underwent RENAL TRANSPLANTATION .
* Kidney was donated by his mother who is 50 year old lady . He is apparently Normal with no complains .

12/05/21 

                  Discharge report 

Report :
 




Daily update 
17/12/21 ( 2nd day )
BP : 120/80 mmHg 
PR : 72 bpm
RR : 12 cpm

18/12/21 ( 3rd day )
BP : 120/80 mmHg
PR : 82 bpm
RR : 18 cpm
 Tab. WYSOLONE 7.5 mg PO/OD
Tab. TACROLIMUS 3mg -x- 2mg 
Tab. MYCOFENOLATE 750 mg PO/BD 
Tab. OMEZ PO/OD 
Tab AMLONG PO/TID 10mg -5mg - 10mg 
Tab. ARKAMINE 0.2 mg PO/BD 1-x-1
Tab. B- Complex PO/OD
Tab. MET-XL 50 mg PO/BD 
Candid mouth paint for L/A 


19/12/21 ( 4th day )
BP : 130/80 mmHg
PR : 80 bpm
RR : 20 cpm

 Tab. WYSOLONE 7.5 mg PO/OD
Tab. TACROLIMUS 3mg -x- 2mg 
Tab. MYCOFENOLATE 750 mg PO/BD 
Tab. OMEZ PO/OD 
Tab AMLONG PO/TID 10mg -5mg - 10mg 
Tab. ARKAMINE 0.2 mg PO/BD 1-x-1
Tab. FORCAN PO BD
Tab. B- Complex PO/OD
Tab. MET-XL 50 mg PO/BD 
Candid mouth paint for L/A 

 20/12/21 (5th day ) 
BP : 130/70 mmHg
PR : 77 bpm
RR : 18 cpm

 Tab. WYSOLONE 7.5 mg PO/OD
Tab. TACROLIMUS 3mg -x- 2mg 
Tab. MYCOFENOLATE 750 mg PO/BD 
Tab. OMEZ PO/OD 
Tab AMLONG PO/TID 10mg -5mg - 10mg 
Tab. ARKAMINE 0.2 mg PO/BD 1-x-1
Tab. FORCAN PO BD
Tab. B- Complex PO/OD
Tab. MET-XL 50 mg PO/BD 
Candid mouth paint for L/A 

Consulted Ophthalmologist 
LE : 6/6
RE : 6/6 










              



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